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

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0295) and related 
accessories (E0305, E0271). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that these items are medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria have 
not been met for the semi-electric hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the requested semi-electric hospital bed is not medically reasonable and necessary. Our 
physician reviewer found the documentation does not clearly reveal that patient's condition has failed 
positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not 
feasible. The documentation does not support a need for frequent or an immediate change in body position or 
special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not 
medically necessary for this patient. As a result, the requested accessories will also be denied as not reasonable 
and necessary since the base bed is not covered. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the semi-electric hospital bed (E0295) and related accessories (E0305, 
E0271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that 
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water 
and/or phone bill payments (debit card), home assistance services (repairs). 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes 
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or 
phone bill payments (debit card), home assistance services (repairs). You say that you suffer from a 
cardiovascular condition and request a re-evaluation. The Plan denied your request. The Plan says the 
certification dated October 6, 2021, documented that the enrollee has none of the qualifying diagnoses, does 
not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health 
outcomes. 
 
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you 
must have one or more comorbid and medically complex chronic conditions that are life-threatening or 
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization 
or other adverse health outcomes; and must require intensive care coordination.  
 
We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical 
conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, 
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home 
assistance services (repairs).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health care visits.
You asked the Plan to pre-approve home health care. You say that you need wound care 3 times per week. The Plan denied your request. The Plan says the denial of authorization for additional home health is correct, because the medical notes show good wound healing and teaching, education, and frequency of visits should be decreasing due to smaller wounds.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health care. Our reviewer says that you do not meet the Medicare criteria for the requested home health care beyond what the Plan has already approved. Our physician reviewer found the documentation does not support that you require additional skilled nursing services to provide treatment that is medically necessary. You do not require additional skilled nursing to effectively provide treatment, care, and/or services in order to improve your condition or perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health care visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastrointestinal tract imaging to be provided by an outof-
network (OON) provider.
You asked the Plan to pre-approve the OON gastrointestinal tract imaging services. You say that the requested
services are medically necessary and that the medical records provided will justify medical necessity. The Plan
denied your request. The Plan says they do not provide coverage for services received from OON providers
except for emergency and urgently needed care. The Plan says that there are in network providers available
who can supply the care needed.
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 gastrointestinal tract imaging to be provided by an out-of-network
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan has to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found given the persistent and severe symptoms and signs of congestive heart failure (CHF) 
in this enrollee which appears very sensitive to volume loading conditions, the complexity of the medical 
regimen and the failure to prevent acute CHF hospitalization, use of the CardioMEMS device is reasonable and 
has clinical data, expert opinion, and approved FDA indications to support its use in selected appropriate 
clinical situations like this one. It would therefore meet the medical reasonableness and necessity criteria of the 
applicable CMS Section 1862(a) 1(A) rule. 
 
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 CardioMEMS device have been met. Therefore, we decided that the Plan has 
to pre-approve a CardioMEMS device.  
 
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 laboratory testing provided on June 24, 2021. 
 
You asked the Plan to pay for lab test. You say that this procedure is medically necessary and payable. The 
Plan denied your request. The Plan says the denial of payment for this testing is correct, because this test was 
performed for screening purposes which is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in 
the Medicare rules section, are not covered. 
 
The test at issue in this appeal, lab test, was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory 
testing provided on June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for two additional units of hand x-rays (73130) provided on 
April 23, 2021. 
 
You asked the Plan to pay for two additional units of hand x-rays. You say that the enrollee had multiple 
exams. The Plan denied your request. The Plan says this was previously billed and pays. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 additional units of CPT code 73130 are not supported in the medical record. The medical record 
only supports 2 units of CPT code 73130, which were previously billed and paid. Based on this information, we 
decided that Medicare rules for coverage of two additional units of hand x-rays have not been met. Therefore, 
we decided that the Plan does not have to pay for two additional units of hand x-rays (73130) provided on April 
23, 2021.
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 a Trilogy machine will help your 
breathing issues and give you a better quality of life. You say that a bi-level positive airway pressure (BiPAP) 
machine is not appropriate since it is not capable of providing aggressive tidal volumes and back up rate if 
needed to provide prevent hypercapnia. You say that you require a long-term aggressive treatment and the use 
of a BiPAP machine first would put you at risk for further exacerbation, treatments, and hospital stays. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for coverage of the 
requested item. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 

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 portable ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This enrollee has chronic obstructive pulmonary disease (COPD), but there is no 
documentation of carbon dioxide (CO2) retention.  Medicare does not cover a ventilator when used as BiPAP.  
Certain BiPAP devices can provided the Average Volume Assured Pressure Support (AVAPS) mode of 
support. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia (D9239, D9243) for dental services. 
 
You asked the Plan to pre-approve the services. You say that this is needed because of your age. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pre-approve 
anesthesia (D9239, D9243) for dental services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections provided on January 27, 2021. 
 
You asked the Plan to pay for the vitamin injections. You say that these procedure codes are valid and have 
been properly coded based on the type of treatment performed. You say that electrical nerve stimulation 
provides comparable effectiveness and hope the matter can promptly be settled. The Plan denied your request. 
The Plan says the denial is upheld. 
  
The Plan must follow Medicare rules. Medicare rules say that outpatient physical therapy services are paid for 
only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or 
incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may 
perform physical therapy services under State law. Medicare rules say also that claims for compounded drugs 
shall be submitted using a compounded drug, not otherwise classified (NOC) code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vitamin injections have not been met. Specifically, the physical therapy services at issue in this 
case were rendered by an NP/PA who is not licensed to provide physical therapy. Also, the drug reported on 
this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug 
be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, 
payment cannot be made. Therefore, we decided that the Plan does not have to pay for the vitamin injections 
provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays
(D0274), and periodontal maintenance (D4910) provided on May 27, 2021, by a Medicare opt-out provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and periodontal maintenance. You
say that you have visited this same dental office several times in the past year and were reimbursed. You also
say that the Plan failed to inform you that this provider had opted out. The Plan denied your request. The Plan
says you received these services from a provider who chose not to receive Medicare funds. The Plan also says
that the treating provider opted out of Medicare effective April 14, 2021, to April 14, 2023.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and periodontal
maintenance (D4910) provided on May 27, 2021, by a Medicare opt-out provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ophthalmic biometry services you received at an outpatient hospital facility on May 26, 2021.
You asked the Plan to waive the coinsurance for the ophthalmic biometry services. You say that these services weren't rendered, so you shouldn't have to pay the coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for outpatient hospital services. You have been asked to pay 20% coinsurance for the ophthalmic biometry services. We reviewed the medical records from this date of service. The medical records confirm that on May 26, 2021, you went to the hospital
for a follow-up visit. During that visit, ophthalmic biometry services were performed. The ophthalmic biometry services fall within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ophthalmic biometry services you received at an outpatient hospital facility on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 7, 2020, by an out-of-network provider.
You asked the Plan to pay for physician services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 physician services provided on February 7, 2020, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider 
from June 1, 2021, through June 30, 2021. 
 
You asked the Plan to pay for out-of-network physical therapy. You say that the medical records warrant the 
medical necessity of the service billed. You say that the medical documentation should be reviewed, and the 
claim reprocessed for payment. The Plan denied your request. The Plan says out-of-network services were not 
authorized. 
  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 
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 physical therapy provided by an out-of-network 
provider from June 1, 2021, through June 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials and clinical staff time provided from December 30, 2021, through April 16, 2021.
You asked the Plan to pay for the additional supplies, materials and clinical staff time. You say that the medical records fully justify billing code 99072 as they clearly show what kind of precautions were taken prior to treating the patient. You say that all the dates of service should be reprocessed for prompt payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies, materials and clinical staff time have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials and clinical staff time provided from December 30, 2021, through April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician care plan oversight services (G0181) provided on 
March 31, 2021, by an OON provider. 
 
You asked the Plan to pay for the care plan oversight services. You say that care plan oversights are a Medicare 
covered service. Please reprocess the claim as it is medically necessary to establish an effective treatment plan 
for the good of the enrollee. The Plan denied your request. The Plan says enrollee's must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 physician care plan oversight services (G0181) 
provided on March 31, 2021, by an OON provider.