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

 
We decided that the Plan has to pay for the home air conditioning unit (99199) purchased December 29, 2021. 
 
You asked the Plan to pay for the air conditioner. You say that under your old Plan the AC unit was covered. It 
cost you $177. You have COPD and the Plan never called your doctor to get the results. The Plan denied your 
request. The Plan says that the enrollee was not in the COPD case management program during all or part of 
the service dates billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan has not substantiated their reason to continue to deny. The Plan has not 
provided any records to verify if the enrollee does not have COPD nor was any information provided showing 
that this enrollee was not in the TX Respiratory Care Management program on the date of service. Therefore, 
we decided that the Plan has to pay for the home air conditioning unit (99199) purchased December 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 28, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on October 28, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ramelteon. 
 
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 self-administered drugs are not covered. 
 
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. Therefore, we decided that the Plan does not have to pre-approve Ramelteon.  
 
Benefits for these 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on October 20, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says it is not seen that the enrollee could not be transported in a wheelchair van or an automobile. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
reviewed documentation indicates that the enrollee was transported to a nursing facility from an emergency 
department. There was no documentation provided indicating that you could not have been transported in a 
wheelchair van or an automobile. There is no documentation indicating that the enrollee was unable to tolerate 
sitting upright during transport. The review has determined that the documentation did not support that other 
means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for this patient. The documentation did not support that the patient needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport on October 20, 2021. The documentation did not support that the ambulance transport on was medically reasonable and necessary for the patient on October 20, 2021. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on October 20, 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 September 18, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
paramedics never advised you that your insurance would not pay if you were not transported to the hospital. 
You also say that you should not be required to pay for the service. The Plan denied your request. The Plan 
says Medicare only covers ambulance transport. The Plan also says that Medicare does not cover paramedic 
assessment when there is no transport to the hospital. 
 
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 September 18, 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 September 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Victoza. 
 
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 self-administered drugs are not covered. 
 
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. Therefore, we decided that the Plan does not have to pre-approve Victoza.  
 
Benefits for these 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroplasty, acetabular and proximal femoral prosthetic 
replacement (total hip arthroplasty) (27130) provided December 22, 2021 by a surgical assistant. 
 
You asked the Plan to pay for the surgical procedure. You say that your surgical assistant provider was 
requested to assist in this enrollee's surgery by the surgeon and/or facility. Provider selection was beyond the 
control of the enrollee. The Plan denied your request. The Plan says this provider is not certified/eligible for 
payment on this date of service. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) (27130) provided 
December 22, 2021 by a surgical assistant.
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 the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
appears to be improving and should only require short-term additional acute care services that can be safely 
completed at the current facility until more stable and appropriate for a lower level of care. The enrollee does 
not require services at the LTACH that are not already available at the current facility. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to LTACH is not medically necessary at this time as it would not be clinically advantageous. Completion of 
treatment at the current facility is 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Aripiprazole tablet. 
 
You asked the Plan to pre-approve Aripiprazole. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Aripiprazole 
tablet.  
 Benefits for Aripiprazole 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 waive the copayment for a diagnostic eye exam provided on 
September 22, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you did not authorize anything 
more than a routine exam. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $30 
copayment for each service for the diagnosis and treatment of diseases and injuries of the eye.  
 
The file shows that the Plan reprocessed the claim from October 28, 2021, and removed the copayment. You 
have been asked to pay a $30 copayment for the eye for the eye exam provided on September 22, 2021. The 
billing code used for this case was a diagnostic code, which would not fall under the routine exam benefit. The 
eye exam falls within the Vision Care 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 
diagnostic eye exam provided on September 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy services provided to the enrollee on May 5, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code is not appropriate for the services. 
 
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 49653 is "Laparoscopy, surgical, repair, ventral, 
umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or 
strangulated." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the enrollee presented on 5/3/21 with 
findings of an epigastric hernia. There is no imaging or physical exam findings that support that the hernia was 
incarcerated. The patient underwent laparoscopic epigastric hernia repair with mesh on 5/5/21. There is no 
mention of strangulation or incarceration of bowel or fat. The correct CPT code should therefore be 49652 - 
Laparoscopy, surgical repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when 
performed); reducible. CPT 49653 is for an incarcerated epigastric hernia, which is not supported by the operative note. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laparoscopy services provided to the enrollee on May 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional facet injections. 
 
You asked the Plan to pre-approve additional facet injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary 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 additional facet injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had 
radiofrequency ablation (RFA) on May 31, 2022, and now the request is for additional facet injections. This 
does not meet the criteria of greater than 50% pain relief for 3 months. Therefore, the request, at this time, is 
deemed not medically reasonable or 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 additional facet injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional facet injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on November 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim to be reprocessed for payment. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no referral from an in-network provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on November 8, 
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 stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you have bad arthritis, have fallen before and 
broke your leg. To avoid that happening again you would like the stair lift. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care (G0179) provided on February 4, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health care. 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 were 
non-emergent and prior authorization was not obtained. 
 
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. Wae 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 home health care (G0179) provided on February 4, 
2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an oxygen concentrator and a portable 
oxygen system provided from January 1, 2022, to February 2, 2022. 
 
You asked the Plan to waive the copayment for an oxygen concentrator and a portable oxygen system. You say 
that you never had to pay a rental period when switching insurance companies before. The Plan denied your 
request. The Plan says you were charged the correct cost sharing amount. 
 
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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for all other covered DME items for an oxygen concentrator 
and a portable oxygen system.  
 
 
 Claim Number: Date of Service: Allowed Amount: 20% Coinsurance: 
20220224005601 January 1, 2022 $16.05 $3.21 
20220224005601 January 1, 2022 $72.84 $14.57 
20220225002841 February 1, 2022 $16.05 $3.21 
20220225002841 February 1, 2022 $72.84 $14.57 
 Total: $177.78 $35.56 
 
An oxygen concentrator and a portable oxygen system falls within the Durable medical equipment (DME) and 
related supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an oxygen concentrator 
and a portable oxygen system provided on January 1, 2022, to February 2, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records 
provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees medical conditions are reported to be stable with no issues that require a physicians evaluation three or more times per 
week. The enrollee does require physical therapy and occupational therapy services, but the medical records 
provided do not clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. 
Provided records do not explain why the intensive inpatient rehabilitation therapy program is necessary and 
why therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the enrollee. 
 
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.