Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on June 1, 2022. 
 
You asked the Plan to pay for hospital outpatient clinic visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for hospital outpatient clinic visit provided on June 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has orthopedic issues and can tolerate 
IRF therapy. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Orthovisc is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have knee 
pain due to osteoarthritis. The records do not indicate that you have failed or are unable to complete three 
months of conservative therapy. The criteria for coverage are not met and the Orthovisc is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim was denied incorrectly. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a monaural, digital hearing aid (V5257) provided on March 
10, 2022. 
 
You asked the Plan to pay for a monaural, digital hearing aid (V5257). You say that the provider who 
prescribed and sold you the hearing aids and indicated that they were reimbursable by Medicare. The Plan 
denied your request. The Plan says per the member's 2022 EOC, hearing aids must be purchased through the 
Plan to be covered under the hearing aid services offered by the Plan. 
 
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 they are purchased through providers other than the Plan hearing services.  
 
 
  We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of a monaural, digital hearing aid (V5257) have not been met. Therefore, we 
decided that the Plan does not have to pay for a monaural, digital hearing aid (V5257) provided on March 10, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a lower limb prosthetic cover (L5704). 
 
You asked the Plan to pre-approve a lower limb prosthetic cover (L5704). You say that the requested lower 
limb prosthetic cover (L5704) is medically necessary. The Plan denied your request. The Plan says that the 
requested lower limb prosthetic cover (L5704) 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 a lower limb prosthetic cover (L5704). 
Our reviewer says that the requested lower limb prosthetic cover (L5704) is medically necessary. Our 
physician reviewer found based on the medical records provided there is documentation that the lower limb 
prosthetic cover (L5704) at issue in this case meets Medicare criteria for medically reasonable and necessary 
for the enrollee. As stated in the Local Coverage Article-Lower Limb Prostheses-Policy Article (A52496): 
"Lower limb prosthetic covers (L5704, L5705, L5706, and L5707) are complete products and afford shape, 
protection and waterproofing for normal daily usage of the prosthesis. They offer sufficient protection and 
weatherproofing for beneficiaries who require lower limb prosthetics." The health plan denied coverage for the 
cover stating that: "When an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis 
(L5510, L5520, L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and 
components are covered in accordance with the functional level assessment except for codes L5629, L5638, 
L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not reasonable and 
necessary." In this case the patient is being supplied with a below knee prosthesis (L5301) not an L5500, 
L5510, L5520, L5530 or L5540. 
 
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 lower limb prosthetic cover (L5704) have been met. Therefore, we decided 
that the Plan has to pre-approve a lower limb prosthetic cover (L5704).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for services provided on April 11, 2022. 
 
You asked the Plan to pay for the testing services. You say that a signed order was received. The Plan denied 
your request. The Plan says the code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 82728 is Ferritin. We find that CPT code 82728 is not 
supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
billed for services provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D9610, D1208, D4346, D9230) provided on 
July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services (D9610, D1208, D4346, D9230) provided on July 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on May 14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code was medically necessary. The Plan 
denied your request. The Plan says the code is not separately payable. 
 
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 93041 is a packaged code when billed on the same claim as a code assigned a status 
indicator of S, T, or V, such as code 99284. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the outpatient hospital services provided on May 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 11, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you were under the impression that the services 
were authorized by the Plan and that the laboratory providing the services was an authorized laboratory. The 
Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 laboratory services provided on October 11, 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 portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for the 
enrollees condition. The Plan denied your request. The Plan says Medicare does not cover ventilators used as 
requested and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable 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 reduce or waive the copayment for an injection provided on May 19, 
2022. 
 
You asked the Plan to reduce or waive the copayment for an injection. You say that you were unaware that the 
hospital would send a claim for an injection that was performed in the provider's office. You also say you paid 
the specialist copay of $45 that day. 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 $350 for 
outpatient hospital services.  
 
 
 
 
 You have been asked to pay $350 for an injection. This item/service 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 reduce or waive the copayment for an injection provided 
on May 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99239 billed for services provided on June 14, 2021. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was in need of care as illustrated by 
medical records. The Plan denied your request. The Plan says that the billed service cannot be verified. 
 
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. 
 
We looked at the file and the rules. The Plans summary of this case, and the appeal indicate that medical 
records were provided. This is further evident by the Plans decision to overturn code 99233. However, the 
medical records submitted by the appellant were not provided by the Plan. The Plan has not made reasonable 
and diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for procedure code 99239 billed for services provided on June 
14, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary, and the enrollee can safely receive the 
services they need in other settings, for example: a skilled nursing facility or home with home health. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating leg rests and a power tilt and recline system 
for a power wheelchair. 
 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are covered 
when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have a 
history of amytrophic lateral sclerosis (ALS), diabetes, and chronic kidney disease. You are not able to 
ambulate on your own. There is no documentation that you have significant swelling (edema) of the lower 
extremities, a musculoskeletal condition, or a cast or brace that prevents 90 degree flexing of the knee. The 
power elevating leg rests are therefore not medically necessary. You do not have any pressure injuries or 
require intermittent catheterization; therefore, the power tilt and recline is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve elevating leg rests and a power tilt and recline system for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the sensor. You say that you are currently using Freestyle Libre 2 products 
but want to switch to Freestyle Libre 3 since its smaller. The Plan denied your request. The Plan says that the 
sensor is not necessary.  
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the sensor. Our physician reviewer 
found the Libre 3 is smaller and the MARD (a measure of accuracy) is improved; therefore, it should be 
approved. 
 
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 sensor have been met. Therefore, we decided that the Plan has to pre-
approve the FreeStyle Libre 3 sensor.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that you are missing part of your spine, are 
in terrible condition, and need to see this doctor. You say that you have heart and respiratory failure and have 
not been able to get to appointments. The Plan denied your request. The Plan says the requested transportation 
does not meet the criteria for coverage. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each trip does not exceed 50 miles of driving distance.  
We looked at your request, the records in the case file, and the rules. The records show that transportation is 
being requested to a location that is more than 50 miles from your home. This means that it exceeds the benefit 
allowance for routine transportation coverage. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve routine transportation.