Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
26, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that she cannot afford the 
copay. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $225 copayment per one-way trip for ambulance services.  
 
 
 
 
 
 The enrollee has been asked to pay a $225 copayment for the ambulance services. The ambulance services fall 
within the Ambulance Services 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 
the ambulance services provided on April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home electrical generator (E1399). 
 
You asked the Plan to pre-approve a home electrical generator. You say that you have serious lung disease, and 
you need oxygen to survive. The last time your electricity was shut off, you were unable to breathe, and you 
were suffocating. You also say that if your electric company shuts off your power, you will need a back-up 
generator. The Plan denied your request. The Plan says the home electrical generator 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. 
 
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 home electrical generator (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on March 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that the services provided were medically 
necessary. 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 domiciliary services provided on March 29, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement and trimming of the skin provided on April 
18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nail debridement and trimming of the skin. You say that the enrollee presented 
the incorrect insurance card at the time of service. Therefore, the office was unable to obtain authorization. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. Although you indicated the member provided an incorrect insurance card, it is the office's 
responsibility to verify the member's insurance. 
 
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 nail debridement and trimming of the skin 
provided on April 18, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from February 3, 2022, to February 
21, 2022. 
 
You asked the Plan to pay for the home health services. You say that you have mailed in the NOA four times 
and faxed it once. The Plan denied your request. The Plan says that the date listed on the NOA does not match 
the date on the final claim for the dates of service in this case. The Plan says that a valid NOA is required. 
 
The Plan must follow Medicare rules. Medicare rules say that the HHA shall submit an NOA with a one-time, 
artificial 'admission' date corresponding to the "From" date of the first period of continuing care in 2022. Only 
one NOA is required for any series of Home Health periods of care beginning with admission to home care and 
ending with discharge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have been met. Therefore, we decided that the Plan has to pay for the 
home health services provided from February 3, 2022, to February 21, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided December 29, 2021. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed 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. 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, this service is included in 
procedure 32555 which was also performed. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for radiology services (71045) provided December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that this is medically necessary for your condition. 
The Plan denied your request. The Plan says stairway elevators/stairlifts are not covered because they are a 
convenience item and not primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair glide.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty wheeled walker (E0149) and a walker seat 
attachment (E0156). 
 
You asked the Plan to pre-approve a heavy-duty wheeled walker and a walker seat attachment. You say that 
you need the requested walker due to the diagnoses of malignant related fatigue and morbid obesity. The Plan 
denied your request. The Plan says you weigh less than 300 pounds and do not meet the Medicare criteria for a 
heavy-duty walker. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that you weigh less than 300 pounds. Medicare 
rules say you must weigh over 300 pounds to meet criteria of the requested walker. Based on this information, 
we decided that Medicare rules for coverage of a heavy-duty wheeled walker and a walker seat attachment 
have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve a heavy-duty wheeled walker (E0149) and a 
walker seat attachment (E0156).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery. 
 
You asked the Plan to pre-approve the requested item. You say that you have problems with power outages. 
The Plan denied your request. The Plan says the external batteries are not covered by Medicare. 
 
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. 
 We looked at the file and the rules. The backup batteries are considered a duplicate. The backup batteries also 
do not serve a purpose that is primarily medical in nature. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve a backup battery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy administration of a pembrolizumab 
injection provided on November 24, 2021, by an OON provider. 
 
You asked the Plan to pay for the chemotherapy administration of a pembrolizumab injection. You say that you 
are requesting reconsideration stating the claim was denied stating more info is needed regarding authorization. 
You say that authorization was updated with a correct tax ID. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan 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 chemotherapy administration of a 
pembrolizumab injection provided on November 24, 2021, by an OON provider.
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 are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The records provided support the necessity of the requested service. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF admission. Care can 
be provided in another setting such as skilled nursing facility, outpatient setting or home health 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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical conditions appear stable on outpatient medications with 
no issues that appear to require a physicians evaluation three or more times per week. The enrollee does 
require physical therapy and occupational therapy services, but the medical records provided do not clarify why 
the enrollee requires an intensive inpatient rehabilitation therapy program. Provided medical records do not 
explain why the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower 
level of care such as in a skilled nursing facility is not appropriate for the enrollee. There is no documentation 
that the enrollee requires the intensive medical care and the intensive rehabilitation therapy program provided 
in an inpatient rehabilitation facility. The medical records do not clarify that treatment at the skilled nursing 
facility level is not appropriate in this case. 
 
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: 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 concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says a physician review of the information provided has determined that the equipment 
provided continues to adequately meet medical needs. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found that you 
chronic obstructive pulmonary disease, and have been provided with a stationary oxygen concentrator and 
portable tanks, size not specified. You are having trouble handling the portable tanks. The D cylinder is only 
slightly heavier than a standard portable concentrator. This tank can be provided by the vendor. And the 
records show no documentation that SpO2 can be maintained over 91% during exercise with flow rate 1 to 4 
L/min using an oxygen conserving device. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing in the upper and lower 
right quadrants (D4341) provided on January 21, 2022, and periodontal scaling and root planing in the lower 
left quadrant (D4341) provided on January 27, 2022. 
 
You asked the Plan to pay for periodontal scaling. You say that you told the provider and billing department to 
only do services that were covered by your benefits. The Plan denied your request. The Plan says periodontal 
scaling and root planing (D4341) is not covered by your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing in the upper and lower right quadrants (D4341) provided on January 21, 
2022, and periodontal scaling and root planing in the lower left quadrant (D4341) provided on January 27, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 provided on December 20, 2021. 
 
You asked the Plan to pay for the billed services. You say that the code was billed with a modifier to be paid 
separately. The Plan denied your request. The Plan says no modifiers are allowed with this code pair. 
 
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 93355 
is a column II code to column I code 00560 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 93355 provided on December 20, 2021.
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 believe the enrollee's medical management and 
rehabilitation needs require an inpatient rehabilitation stay and close physician supervision. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for an admission to an IRF. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer also found that there is not a reasonable expectation 
that this 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.