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

 
We decided that the Plan has to pre-approve an eye-gaze wheelchair-drive interface. 
 
You asked the Plan to pre-approve an eye-gaze interface. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for coverage of the 
requested item 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 an eye-gaze interface. Our reviewer 
says that the requested item is considered medically reasonable and necessary in this case. Our physician 
reviewer found that clinical documentation shows that the enrollee has amyotrophic lateral sclerosis (ALS) 
with progressive weakness. The requested eye-gaze interface is medically necessary for the enrollee to continue 
operating the current power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an eye-gaze interface have been met. Therefore, we decided that the Plan has to 
pre-approve an eye-gaze wheelchair-drive interface.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on April 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an ultrasound. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the services were not referred by a network provider or rendered in an in-
network facility. The services were not urgent or emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 ultrasound provided on April 27, 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 the standing frame/table system (CPT code E0638). 
 
You asked the Plan to pre-approve the standing table. You say that your physical therapist recommended the 
standing frame system for your condition. You state that you are unable to progress further in physical therapy 
and are unable to regain the ability to walk because you are not able to stand on your own. The Plan denied 
your request. The Plan says the standing table 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 standing stable is not a covered benefit because they are not primarily medical in nature. 
Therefore, we decided that the Plan does not have to pre-approve the standing frame/table system (CPT code 
E0638).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided from 
January 18, 2021, to November 23, 2021. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that these tests are being done 
in your home not in office and you were told there was no copayment. The Plan denied your request. The Plan 
says the copayment applied is correct. 
 
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 $40 
copayment for physician specialist services (including surgery second opinion, telehealth, and urgently needed 
services).  
 
 
 You have been asked to pay $440 ($40 x 11 visits) copayment for specialist office visits. Specialist office visits 
fall within the Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visits provided from January 18, 2021, to November 
23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair 
(E2377, E2313, E2311). 
 
You asked the Plan to pre-approve the expandable controller for a power wheelchair. You say that the 
expandable controller medically necessary. The Plan denied your request. The Plan says coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that and expandable controller is covered when 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 the expandable controller for a power 
wheelchair. Our reviewer says that the expandable controller is not medically necessary. Our physician 
reviewer found the records document that the enrollee is independent with feeding, toileting, meal preparation, 
grooming and dressing, thus indicating she has adequate upper extremity strength and function to operate the 
wheelchair's power options with their own switches.  
 
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 expandable controller for a power wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, 
E2313, E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on May 9, 
2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that since you were discharged 
from a recovery room it should be covered. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
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 $335 
copayment per day, per admission.  
 
You have been asked to pay $335 copayment for inpatient hospital stay. 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 inpatient 
hospital stay provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001). 
 
You asked the Plan to pre-approve the standard wheelchair. You say that the wheelchair is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for a wheelchair to be covered, the beneficiarys 
mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. 
 
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 standard wheelchair. Our reviewer 
says that the wheelchair is not medically necessary. Our physician reviewer found the provided records do not 
document clearly that the patient's mobility deficit cannot be helped by the use of a walker. 
 
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 standard wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 11, 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 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 an office visit provided on February 11, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 4, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are being overcharged for 
the procedure due to where you had it done. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
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 $310 
copayment for each outpatient hospital service visit.  
 
You have been asked to pay $310 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 outpatient surgery provided 
on May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure machine and shower chair. 
 
You asked the Plan to pre-approve the items. You say that the enrollee would greatly benefit from receiving a 
blood pressure monitor. The Plan denied your request. The Plan says the items you are requesting are not 
covered by Medicare or the enrollees Health Plan. The Plan states the enrollee's information indicates that 
their Health Plan provides a monthly OTC benefit of $30 per month and the OTC benefit may be used towards 
obtaining a blood pressure machine. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension. Medicare rules say that shower chairs are not covered because 
they are not primarily medical in nature.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Furthermore, 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 blood pressure 
machine and shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections for knee pain. 
 
You asked the Plan to pre-approve platelet rich plasma injections for knee pain. You say that you want to try 
platelet rich plasma injections since the cortisone injections did not help with your pain, and you heard this 
helps with severe pain. The Plan denied your request. The Plan says platelet rich plasma injections for knee 
pain does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve platelet rich plasma injections for knee 
pain. Our reviewer says that platelet rich plasma injections for knee pain are not medically necessary. Our 
physician reviewer found that at present, the evidence is insufficient to determine the effects of platelet rich 
plasma (PRP) on health outcomes for osteoarthritis. The existing evidence and lack of accepted standards of 
medical practice for PRP injections do not meet the requirement of medically reasonable and 
necessary. Therefore, PRP injections and PRP combined with stem cells for musculoskeletal injuries and/or 
joint conditions, whether primary or adjunctive use, are not medically reasonable and 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 platelet rich plasma injections for knee pain. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve platelet rich plasma injections for knee pain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with 
calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic 
compressor (E0667). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee did not have a trial of a basic pump as is required by Medicare. 
 
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 DME. Our physician reviewer 
found the provided records did not describe a trial and failure of a basic pump to support this request or 
documentation of examined truncal edema to justify bypassing this trial. Therefore, without sufficient objective 
documented support made, the advanced pump will be considered not medically necessary at this time. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code 
E0652) and segmental pneumatic appliance for use with pneumatic compressor (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in tub. 
 
You asked the Plan to pre-approve a walk-in tub. You say that a walk-in tub is necessary. The Plan denied your 
request. The Plan says a walk-in tub is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The walk-in tub is not covered because it is not medical in nature and is regularly and 
primarily used by persons who do not have a specific medical need for them. Therefore, we decided that the 
Plan does not have to pre-approve a walk-in tub.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on March 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the chest x-ray rendered on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 28, 2021, to 
September 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health 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 home health services provided on June 28, 2021, 
to September 23, 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 ten (10) additional months for a TENS device (E0720). 
 
You asked the Plan to pre-approve the TENS device. You say that the TENS device is necessary. The Plan 
denied your request. The Plan says they approved a TENS device for a two-month trial; however, the 
remaining ten months of the year requested have been denied. 
 
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 TENS device. Our physician 
reviewer found there is no documentation that the TENS device at issue in this case meets Medicare/LCD 
criteria for medically reasonable and 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 TENS device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ten (10) additional months for a TENS device (E0720).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on April 1, 2022. 
 
You asked the Plan to pay for acupuncture. You say that you believe these claims should be treated as 
specialist visits instead of being denied altogether. The Plan denied your request. The Plan says acupuncture is 
only covered under Medicare for chronic low back pain. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture is only covered under Medicare for 
chronic low back pain. Records show that the acupuncture was to treat osteoarthritis. Therefore, we decided 
that the Plan does not have to pay for acupuncture provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services provided on February 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that the authorization for services should 
fall under the facilities authorization and you would like reimbursement for the services provided. The Plan 
denied your request. The Plan says the rendering and referring providers are both OON providers and there was 
no 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 the ophthalmological services provided on 
February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses provided on March 24, 2022. 
 
You asked the Plan to reimburse you for eyeglasses. You say that  The Plan denied your request. The Plan says 
the Mandatory Supplemental Vision benefit exclusions include, but are not limited to, any benefits received at 
a non-network optical provider. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a network 
optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on 
March 24, 2022.