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

 
We decided that the Plan does not have to pay for the durable medical equipment provided on August 11, 2022. 
 
You asked the Plan to pay for the provided equipment. You say that there were supply chain issues. The Plan 
denied your request. The Plan says this is not a Medicare qualified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided 
on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (E1230). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need this item for community 
activities. The Plan denied your request. The Plan says a power wheelchair used for outside the home is not 
covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair (E1230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823) and hooks (E1399). 
 
You asked the Plan to pre-approve a power wheelchair and hooks. You say that your current rented wheelchair 
is difficult to use on ramps and buses. The Plan denied your request. The Plan says this item is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair (K0823) and hooks (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the hearing aids (Current Procedural Terminology 
(CPT) code(s) V5261-LT and V5261-RT) and sales tax (S9999) purchased on July 11, 2022. 
 
You asked the Plan to reimburse you for hearing aids and sales tax. You say that you want the Plan to 
reimburse you. The Plan denied your request. The Plan says your hearing aid benefit is limited to the 
TruHearing branded hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids limited to the TruHearing branded hearing aids.  
 
 
 We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids and sales tax have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the hearing aids (Current Procedural Terminology (CPT) code(s) V5261-LT and V5261-RT) 
and sales tax (S9999) purchased on July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee needs a ventilator. The Plan denied 
your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent prior to the fall and need more 
intense rehabilitation than what you are currently receiving. The Plan denied your request. The Plan says your 
medical and therapy needs could be met in a skilled nursing unit. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on July 
29, 2022, to July 31, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copayment. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment per visit for emergency care.  
 
The enrollee has been asked to pay a $90 copayment per visit for emergency room services. The total amount 
you are being asked to pay is $180 ($90 x 2 visits = $180). This item/service falls within the emergency care 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency room services 
provided on July 29, 2022, to July 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on August 3, 
2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that these charges should not bundle as the 
physicians have different specialties. The Plan denied your request. The Plan says this service is denied due to 
being bundled as part of the global surgical fee because it was reported within 10 days of the minor surgical 
procedure, insertion of tunneled centrally inserted central venous catheter (36558). 
 
The Plan follows Medicare rules. Medicare rules say that the Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, 
postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery.  
 
 
  We looked at the file and Medicare rules. Review of the file shows that the enrollee had insertion of tunneled 
centrally inserted central venous catheter performed on August 1, 2022. The Medicare Fee Schedule Data Base 
(MFSDB) shows that the postoperative period for this code is 10 days. The enrollee received subsequent 
hospital care on August 3, 2022, which is two days after the initial procedure. Therefore, this procedure is 
bundled as part of the global surgical fee because it was reported within 10 days of the minor surgical 
procedure (36558). Based on this information, we decided that Medicare rules for coverage of the subsequent 
hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99233) provided on August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 8, 
2022 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. 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 $395 
copayment for outpatient surgery/Medicare-covered surgery or other services provided to you at an outpatient 
hospital.  
 
You have been asked to pay a $395 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery or other services provided to you at an outpatient hospital 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 outpatient surgery provided on July 8, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transition lenses, progressive lenses, polycarbonate 
lenses, and anti-reflective coating purchased on May 4, 2022. 
 
You asked the Plan to pay for the upgraded lenses. You say that you feel that you should not have to pay for 
these glasses because you cannot see out of them. The Plan denied your request. The Plan says you were 
instructed to go back to the original provider to have the lenses adjusted, but you did not want to go back to 
them. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the lenses are standard plastic eyeglasses lenses. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you received transition lenses, 
progressive lenses, polycarbonate lenses, and anti-reflective coating, which are considered lens upgrades, and 
are not covered under your plan. Based on this information, we decided that the Plan's rules for coverage of the 
upgraded lenses have not been met. Therefore, we decided that the Plan does not have to pay for the transition 
lenses, progressive lenses, polycarbonate lenses, and anti-reflective coating purchased on May 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services coded 01402 provided on May 9, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that denial for comprehensive/component procedures. 
 
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. Review of the file shows that the Plan states that the Plan has denied this claim 
due to comprehensive/component procedures. The documentation did not include an explanation, citations, or 
Medicare rules to support this denial. In addition, majority of the case file submitted is illegible. Therefore, the 
Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the anesthesia services 
coded 01402 provided on May 9, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted special service provided on March 14, 2022. 
 
You asked the Plan to pay for the unlisted special service. You say that you want to be reimbursed the cost of 
the dental work that was completed due to an inhaler that was prescribed for a medical reason. The Plan denied 
your request. The Plan says the service is primarily dental in nature and is not a covered service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the unlisted special service 
provided on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 24, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
support 22 or more drug classes were performed. The documentation shows that 15 drug classes were 
performed. This code cannot be verified. 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 drug testing coded G0483 provided on March 24, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the pressure wound needs to be monitored so the 
enrollee can return safely to home. The Plan denied your request. The Plan says that the enrollee's records do 
not show the need for daily skilled nursing, physical therapy, or occupational therapy. Medically necessary care 
may be provided safely in a different level of care. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows the enrollee has had an acute functional status and 
clinical status change thus requiring skilled nursing and therapy. Evaluating therapists recommend daily skilled 
therapy in a SNF thus daily skilled services on an inpatient basis in a SNF is medically appropriate. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 procedure code G0482 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for the billed services. You say that everyone deserves the same level of care. The 
Plan denied your request. The Plan says the documentation does not support the billed code. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. The records do not show that 15-21 drug 
classes were tested. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0482 
billed for date of service August 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs strength to get back and continue 
a normal life before a fall. The Plan denied your request. The Plan says the records do not show that the 
enrollee needs to be seen by a rehabilitation doctor at least three times a week for evaluation of functional and 
medical goals and progress. Medically necessary care may be provided safely in a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found here is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 27, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from January 27, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient psychiatric care from January 
27, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment from January 27, 2023, forward. Our physician reviewer found the enrollee did not require 
inpatient mental health treatment from January 27, 2023, as she was not a danger to herself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from January 27, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 27, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lightweight wheelchair (K0003), purchased on August 
24, 2022. 
 
You asked the Plan to pay for the lightweight wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item is not covered when purchased. 
 
The Plan must follow Medicare rules. The rules say that as of January 1, 2011, standard power wheelchairs are 
only available as capped rental items. Lump-sum purchase is not permitted.  
 
In this case, you purchased the wheelchair. Therefore, we decided that the Plan does not have to pay for the 
lightweight wheelchair (K0003), purchased on August 24, 2022.