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

 
We decided that the Plan does not have to pay for an office visit provided on June 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an office visit provided on June 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2, Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro 2, Motion G device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says neither Medicare nor your plan cover this request. 
Medical studies haven't proven this service/item is helpful for the treatment of the enrollee's health problem. 
 
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 MyoPro 2, Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities.  The requested device is not reasonable and necessary for the diagnosis or treatment of an 
illness or injury or to improve the functioning of a malformed body member. 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 MyoPro 2, Motion G device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a MyoPro 2, Motion G orthotic device (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets the 
Medicare guidelines for LTACH admission. The Plan denied your request. The Plan says the Medicare 
guidelines were not met for LTACH admission, and the enrollee is receiving the care they need in the current 
hospital they are at. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can be safely administered at the current facility until 
more 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 the LTACH is not medically necessary as it 
would not be clinically advantageous at this time. 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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on April 15, 2022. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this 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 pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee in this case has chronic pain and is prescribed opioids for chronic pain control. The 
provided records do not show screening urine drug test results showing inconsistency with current treatment or 
any documented history suggesting drug abuse to justify confirmation testing altogether, let alone for 8-14 drug 
classes. It is not appropriate to routinely test for drug classes that are being used to treat the patient or classes that are not suspected as being used. Therefore, without sufficient supportive information provided for this 
request, the definitive drug testing will be considered 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 the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0842, E1012, 
E2311, E2377, E2313, E2361x2, E1007, E1028x2, E0955). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says the requested items are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
evidence the current level of support with a standard power wheelchair is inadequate. The current wheelchair is 
in disrepair. There is no evidence of a decline in condition warranting and upgrade. She does not have pressure, 
sores, intermittent catheterization, or rely on a ventilator. She had not lost upper body function requiring an 
expandable controller. Criteria per Medicare rules not met. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0842, E1012, E2311, E2377, 
E2313, E2361x2, E1007, E1028x2, E0955).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 May 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on January 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 genetic testing provided on January 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services (92014, 92015, 92202, 92133, 92134, 
92025) provided May 12, 2021. 
 
You asked the Plan to pay for the vision services. You say that you initially filed the claim timely. The Plan 
denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the vision services was not filed until May 17, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the vision services (92014, 92015, 92202, 92133, 92134, 92025) provided 
May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy techniques (97140) and the office visit 
(99212) provided from April 25, 2022, through June 15, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy or by Medicare. 
 
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 the manual therapy techniques (97140) and the office visit (99212) 
provided from April 25, 2022, through June 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee received oral medications and had stable vital signs.  Her lungs were 
clear, and she used CPAP at hs. The enrollee does not require skilled nursing or therapy services on a daily 
basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supply allowance 
provided on March 18, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the coverage criteria is 
not met. 
 The Plan follows 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 pay for the supplies. Our reviewer says that the 
requested supplies are not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has been diagnosed with diabetes mellitus type 2. The current treatment plan for the enrollee 
includes Lantus insulin once daily. As such, the enrollee is not insulin treated with three or more daily 
administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump. The 
enrollees insulin treatment regimen does not require frequent adjustment by the enrollee on the basis of BGM 
or CGM testing results. 
 
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 supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the continuous glucose monitor (CGM) supply allowance provided on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or 
bursa and CoreText or ProText provided on January 17, 2022. 
 
You asked the Plan to pay for arthrocentesis, aspiration and/or injection, major joint or bursa and CoreText or 
ProText. You say that arthrocentesis, aspiration and/or injection, major joint or bursa and CoreText or ProText 
is medically necessary. The Plan denied your request. The Plan says arthrocentesis, aspiration and/or injection, 
major joint or bursa and CoreText or ProText does not meet the requirements for approval. 
 
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 pay for arthrocentesis, aspiration and/or injection, major joint or bursa and CoreText or ProText. Our reviewer says that the arthrocentesis, aspiration and/or 
injection, major joint or bursa and CoreText or ProText is not considered medically reasonable and necessary. 
Our physician reviewer found this is considered an experimental/investigational medication. The procedure and 
injectate are 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 arthrocentesis, aspiration and/or injection, major joint or bursa and CoreText or 
ProText have not been met. Therefore, we decided that the Plan does not have to pay for arthrocentesis, 
aspiration and/or injection, major joint or bursa and CoreText or ProText provided on January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the requested item. You say that the device will allow you go travel longer 
distances. The Plan denied your request. The Plan says your current device is the most appropriate to meet your 
needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that your current oxygen system serves the same purpose as the requested item. Therefore, we 
decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 July 8, 2022, by 
an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transport services provided on December 10, 2021. 
 
You asked the Plan to pay for the ambulance transport services. You say that the ambulance services were 
medically necessary. The Plan denied your request. The Plan says that the members claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. 
 
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 us with proof of hospice enrollment. 
Therefore, we decided that the Plan has to pay for ambulance transport services provided on  
December 10, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments and coinsurance for a diagnostic 
mammogram, laboratory services, and drug injections provided from May 5, 2022, to May 18, 2022. 
 
You asked the Plan to reduce the copayments and coinsurance for the mammogram, lab services, and 
injections. You say that your copayments should only be $50. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for diagnostic procedures and tests, including ultrasounds. 
 
Your contract with the Plan also clearly says that you must pay a $30 copayment for lab services provided in an 
outpatient hospital facility. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for chemotherapy drugs, 
infusion drugs, and all other drugs under Medicare Part B. 
 
You have been asked to pay a $50 copayment for the mammogram on May 5, 2022. This item/service falls 
within the diagnostic procedures and tests, including ultrasounds benefit category. You have also been asked to 
pay a $30 copayment for the lab services on May 18, 2022. This item/service falls within the lab services 
provided in an outpatient hospital facility benefit category. You have also been asked to pay a total of $26.47, 
which is 20% of the allowed amount for the injections on May 18, 2022. These items/services fall within the 
chemotherapy drugs, infusion drugs, and all other drugs under Medicare Part B benefit category. The total for 
all services is $106.47. 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 the copayments and coinsurance for a diagnostic 
mammogram, laboratory services, and drug injections provided from May 5, 2022, to May 18, 2022.