Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vision services (92310, V2531) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve out-of-network vision care. You say that you were approved to see this 
provider in the past, and you feel these services should be covered as they are medically necessary. The Plan 
denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. The 
care in this case is not urgent or emergent, and there are in-network providers who would be able to perform 
the necessary services. In addition, your previous authorization expired in 2019. 
 
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 
vision services (92310, V2531) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services (97124). 
 
You asked the Plan to pre-approve massage therapy. You say that your provider referred you for these services, 
and you do not understand why they are being denied by the Plan. The Plan denied your request. The Plan says 
these services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services (97124).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is not a health plan supplemental benefit that goes beyond the Medicare 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the system. You say that this is needed due to muscular dystrophy. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and diagnostic radiology services provided on 
October 27, 2021. 
 
You asked the Plan to pay for an office visit and diagnostic radiology services. The Plan denied your request. 
The Plan says the service is not covered when it is billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit and diagnostic radiology services provided by on 
October 27, 2021.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided you only require short-term additional acute 
care services that can safely be administered at the current facility. You do not require services at the LTACH 
that are not already available at the current facility. There are no services at the LTACH that you require that 
are not already available and covered at the current facility. 
 
  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were billed correctly. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 9, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transport provided on August 26, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that the patient was discharged from the 
hospital to the skilled nursing facility. The Plan denied your request. The Plan says that transportation of a 
hospital inpatient to another facility for diagnostic tests or special treatment is considered part of the inpatient 
admission, and not separately payable 
 
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. Specifically, the Plan has not provided documents showing the enrollee was 
inpatient on this date of service and was transported to another facility for diagnostic tests and back to the 
hospital on the same date. Therefore, we decided that the Plan has to pay for ambulance transport provided on 
August 26, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme testing provided on November 1, 
2021. 
 
You asked the Plan to pay for the FoundationOne Heme testing. You say that you would like reconsideration 
because this testing was medically necessary. The Plan denied your request. The Plan says this testing is not 
FDA approved, nor does it have clearance as a companion in vitro diagnostic test. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the FoundationOne Heme testing 
provided on November 1, 2021. have been met. Specifically, the documentation submitted does not include 
sufficient clinical information to determine why this testing was ordered, if it was medically necessary or how 
the results will affect the enrollee's treatment. We are unable to determine if the enrollee or laboratory meet the 
criteria for coverage as listed in the National Coverage Determination. Therefore, we decided that the Plan does 
not have to pay for the FoundationOne Heme testing provided on November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omeprazole caplet 40mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says drug coverage is limited only to those covered under the medical benefit. 
 
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 Omeprazole caplet 40mg 
for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
(A0429) with a QL modifier, provided on August 22, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, emergency transport (A0429) with a QL 
modifier. The Plan denied your request. The Plan says the claim was correctly denied for diagnosis not valid 
with procedure billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers report the A0428 (BLS) HCPCS code. 
Providers report modifier QL (Patient pronounced dead after ambulance called) instead of the origin and 
destination modifier. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the 
appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. 
Medicare requires the reporting of A0428 for services provided under these circumstances. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
(A0429) with a QL modifier, provided on August 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance transport. 
 
You asked the Plan to pre-approve the ambulance transport. You say that the services should be covered 
because you are bed confined, you have inability to remain erect due to moderate muscular weakness and 
deconditioning, you have a risk of falling off a wheelchair or stretcher while in motion and the inability to sit 
due to grade II or higher decubitus on buttocks. The Plan denied your request. The Plan says this request cannot 
be granted as the clinical information given doesnt show a covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve ambulance transport.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone 
 
You asked the Plan to pre-approve Prednisone.You have provided records to support coverage of this drug. The 
Plan denied your request. The Plan says this drug is not covered under the patient's medical benefits. 
 
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 Prednisone  
 
Benefits for Prednisone 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 22, 2021, to October 26, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you believe there 
should be no copayment because the provider did complete the procedure the first time. The Plan denied your 
request. The Plan says the proper copayment was applied for the services that were rendered and the enrollee's 
concern for services by the provider was addressed. 
  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 $390 
copayment for In-Network Inpatient Hospital Care per day, for days 1 to 5. The first day of the inpatient 
hospital stay was October 24, 2021, and the last day was October 26, 2021. With 2 days charged as inpatient 
hospital stay the total copayment was $780 ($390 copayment per day x 2 days). 
 
You have been asked to pay a $780 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital 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 
an inpatient hospital stay provided from October 22, 2021, to October 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for imaging and biopsy. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
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 out-of-network referral for imaging and biopsy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says the health Plan requires the use of in-network providers. 
There is not a gap issue and there are in-network providers available who can supply the requested service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and diagnostic radiology services provided on 
December 1, 2021. 
 
You asked the Plan to pay for an office visit and diagnostic radiology services. The Plan denied your request. 
The Plan says the service is not covered when it is billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for an office visit and diagnostic radiology services provided on 
December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electronic connection and skin protection wheelchair seat cushion.
You asked the Plan to pre-approve the electronic connection and skin protection wheelchair seat cushion. You say that you would like reconsideration because the requested equipment is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of the requested equipment.
The Plan follows Medicare rules. Medicare rules say that codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more of the following motors from a single interface. The rules also say that a skin protection seat cushion may be covered when the enrollee has current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface or absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift. 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 electronic connection and skin protection wheelchair seat cushion. Our reviewer says that there is no documentation that it is medically necessary for the the enrollee to control two or more of the motors from a single interface to meet the criteria for coverage of the requested electronic connection (E2310). Provided records document that the enrollee has 4/5 bilateral hand strength and is independent with feeding thus indicating she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. Our physician reviewer found there is no documentation that the enrollee has pressure ulcers or absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift to meet the criteria for coverage of the requested skin protection wheelchair seat cushion (E2603). Records from the enrollee's treating medical provider do not include a physical examination documenting the above required findings. 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 electronic connection and skin protection wheelchair seat cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic connection and skin protection wheelchair seat cushion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (64484) provided on March 9, 2020. 
 
You asked the Plan to pay for an injection. You say that this is supported in the records. The Plan denied your 
request. The Plan says this 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. In this case, we have confirmed that code 64484 
is a column II code to column I code 27096. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for an injection (64484) provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildups, including any pins when required (D2950) 
for tooth #'s 8, 9, and 10. 
 
You asked the Plan to pay for the core buildups. You say that 4 teeth were completely broken due to 
deterioration from medication, and no root canal was required. You also say you requested and were told an 
authorization was received. The Plan denied your request. The Plan says this service is only covered if there is 
a history of a root canal. The Plan also says that tooth #'s 8, 9, and 10 do not meet the criteria for coverage. 
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 because the record does not show that tooth #'s 8, 9, and 10 have had root canals. Therefore, we 
decided that the Plan does not have to pay for the core buildups, including any pins when required (D2950) for 
tooth #'s 8, 9, and 10.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation provided from October 13, 2021, 
through December 2, 2021. 
 
You asked the Plan to pay for electrical stimulation. The Plan denied your request. The Plan says electrical 
stimulation is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for electrical stimulation provided from October 13, 2021, through  December 2, 2021.