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

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on October 
29, 2021, and November 26, 2021. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that since nothing was done at 
the specialist office you shouldn't be charged. 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 $50 
copayment for each specialist office visit for Medicare-covered services. 
 
 
 
 
 You have been asked to pay $100 ($50 x 2 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 on October 29, 2021, and November 
26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on December 
14, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you were told the service 
would 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 $225 
copayment per one way trip (includes ground and air) for each Medicare covered ambulance service.  
 
You have been asked to pay $225 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance services 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 ambulance transport 
provided on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous (IV) infusions, medical supplies, and Part B 
drugs provided on October 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the IV infusions, medical supply, and Part B drugs. You say that you have good 
cause to appeal this claim.  The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the IV infusions, medical supply, and Part B drugs. We found no exception that would require the Plan to pay for 
the IV infusions, medical supply, and Part B drugs. The records provided for review do not show that the 
services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for 
intravenous (IV) infusions, medical supplies, and Part B drugs provided on October 26, 2021, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chair lift provided on May 12, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the chair lift. You say that you were never informed by the Plan representative 
that you needed to use an in-network supplier. You say you should be reimbursed for the covered portion of the 
chair lift. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
chair lift. We found no exception that would require the Plan to pay for the chair lift. Therefore, we decided 
that the Plan does not have to pay for the chair lift provided on May 12, 2021, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that you are appealing the denial of the facet joint 
injections. The injections were covered in 2020. You had nine weeks of physical therapy that you believe was 
in 1998 and you also did aquatic therapy on your own. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria and the service 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 pre-approve the injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has not had a recent trial of conservative therapy such as physical therapy. 
Therefore, the request is deemed 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the facet joint injections (64493, 64494).
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 IRF care is medically necessary as the enrollee needs 
rehab to optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says 
IRF care is not medically necessary and the enrollee's needs can be met in an alternate setting such as in a 
skilled nursing facility, at home with home health services or at home with outpatient therapy. 
 
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 that while the enrollee may benefit from physical therapy, and occupational 
therapy, the enrollee's rehabilitation needs can be safely met in an alternate and lower intensity setting such as 
in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (T2003). 
 
You asked the Plan to pre-approve non-emergency transportation. You say that you are bed-bound and need 
transportation services to get the medical care you need. The Plan denied your request. The Plan says the 
information shows that you have diabetes but do not have congestive heart failure. The Plan also says that since 
you do not have both conditions, the request is not able to be approved. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when you have been diagnosed with both diabetes and congestive 
heart failure (CHF).  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve non-emergency transportation (T2003).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that prior authorization was not present. You say you 
would like the records reviewed and reconsidered. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit urgent or emergent. Therefore, we decided that the Plan does not 
have to pay for the office visit provided on January 7, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 1, 2022, 
to January 17, 2022. 
 You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 1, 2022, to January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for platelets, pheresis, pathogen-reduced, each unit (P9073) 
provided October 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please review and reprocess this claim. The 
Plan denied your request. The Plan says despite multiple outreaches by the Plan, this provider has not 
submitted any clinical records to support the medical necessity of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of platelets, pheresis, pathogen-reduced, 
each unit (P9073) provided October 5, 2021 have been met. The records show that the Plan made multiple 
attempts to obtain medical records from the provider without success. Therefore, we decided that the Plan does 
not have to pay for platelets, pheresis, pathogen-reduced, each unit (P9073) provided October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that at the time of service, the patient informed us that 
she is covered under Medicare. You also say it was impossible to obtain authorization, due to the patient 
misleading you with the incorrect insurance information. The Plan denied your request. The Plan says an 
authorization was not obtained prior to the services being rendered and the provider is not participating with the 
Plan. 
 
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 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (code 97530) provided by a 
chiropractor on February 25, 2022. 
 
You asked the Plan to pay for code 97530. You say that this service was provided in good faith and should be 
paid. The Plan denied your request. The Plan says this is not a covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the therapeutic 
activities (code 97530) provided by a chiropractor on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positive airway pressure face mask (code A7031) 
provided on August 30, 2021. 
 
You asked the Plan to pay for the face mask. You say that the claim was originally submitted with a missing 
modifier, but you acknowledge that the correct coding is A7031 NU KX.  You asked the Plan to add the 
additional modifier. The Plan denied your request. The Plan says you did not bill with the required KX 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that the KX modifier is required for all positive 
airway pressure devices and related supplies. You did not bill with the required KX modifier.  You cannot just 
ask the Plan to add the modifier to your claim for you- you must resubmit your claim with the required 
modifier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the face mask have not been met. Therefore, we decided that the Plan does not have to pay for the 
positive airway pressure face mask (code A7031) provided on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that these orthotics have been a godsend as the next step 
would have been surgery for your bunions. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156). 
 
You asked the Plan to pre-approve HHA services. The Plan denied your request. The Plan says this request 
does not meet the criteria for medical necessity. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 HHA services. Our reviewer says that 
HHA services are not reasonable and necessary. Our physician reviewer found you are medically stable 
without any recent hospitalizations or medical complications. You are receiving personal care services that 
allow for appropriate support and care. Our reviewer also found that the documentation does not support that 
the requested HHA hours are needed to provide adequate support for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HHA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide (HHA) services (G0156).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services provided to the enrollee from 
December 23, 2021, to December 29, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code is not eligible for Medicare purposes. 
 
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 S9366 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9366 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home 
infusion services provided to the enrollee from December 23, 2021, to December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis provided on February 16, 2022. 
 
You asked the Plan to pay for the elbow orthosis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item rendered is not supported by the documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation submitted did not sufficiently support the billed supply code. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the elbow orthosis provided on February 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 4 over the counter (OTC) coronavirus tests 
purchased on January 5, 2022. 
 
You asked the Plan to reimburse you for the OTC coronavirus test. You say that this was the only pharmacy 
close by that sold these tests. You say that a family member was diagnosed with coronavirus. You also say that 
you needed to purchase the tests right away as advised by the hospital. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans or issuers may, but are not required by 
federal law to, provide such coverage for at-home over-the-counter COVID-19 tests purchased before January 
15.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OTC coronavirus test have not been met. Specifically, the file shows that the OTC tests were 
purchased prior to the date of coverage. Therefore, we decided that the Plan does not have to reimburse you for 
the 4 over the counter (OTC) coronavirus tests purchased on January 5, 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 SNF care is medically necessary. The Plan denied 
your request. The Plan says daily therapy is not medically necessary and your needs can be met with 
intermittent physical and occupational therapy three to four times a week. 
 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 skilled nursing facility care. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 skilled nursing facility care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.