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

 
We decided that the Plan does not have to pre-approve a power operated vehicle, scooter (E1230). 
 
You asked the Plan to pre-approve a scooter. You say that you are requesting authorization for a scooter 
because you are unable to walk far due to back surgery and COPD. The Plan denied your request. The Plan 
says the records do not support that the enrollee meets the Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a scooter. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the enrollee requires a power scooter inside the home 
to accomplish mobility related self-care tasks. There is no indication that her mobility deficits cannot be 
overcome by the use of a cane, walker or manual 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 a scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle, scooter (E1230).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional visits. You say that the enrollee's scores indicate that he will 
be hesitant to continue with his home exercise plan independently, increasing his risk of falling. The Plan 
denied your request. The Plan says the requested services are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that in this case, the enrollee has previously been treated with 
outpatient therapies and should be independent with a home exercise program. There is no documentation of a 
recent injury or decline in function. The additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) and a heel stabilizer (L3170) 
provided on February 11, 2022. 
 
You asked the Plan to pay for an ankle-foot orthosis and a heel stabilizer. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS 
have not been met. 
 
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 and when the information in the patients medical record adequately 
supports the medical necessity for the item. 
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The document provided as proof of delivery does not specify the items delivered. The available medical records do not discuss the items at issue. Therefore, we decided that 
the Plan does not have to pay for an ankle-foot orthosis (L1971) and a heel stabilizer (L3170) provided on 
February 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. Although records 
document the enrollee is very limited functionally, provided records do not document a significant 
improvement in the enrollees functional status despite treatment with skilled therapy in the hospital setting and 
there is serious concern about his ability to fully participate with daily therapy due to his reported depressed 
level of consciousness, his dysarthria and his limited ability to follow commands. There is no documentation 
that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do 
not document that services in the home or an assisted living facility with home health care or in a long-term 
care facility on a part time basis are 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, immune globulin and infusion services provided on 
June 7, 2021 to June 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for injection, immune globulin and infusion services. You say that you would like to 
request reconsideration for payment and that you didn't realize the provider was OON. 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 injection, immune globulin and infusion services 
provided on June 7, 2021 to June 8, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient clinical visit provided on January 26, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient clinical 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 outpatient clinical visit provided on January 26, 
2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) 
provided by an out-of-network provider on January 12, 2022. 
 
You asked the Plan to pay for a bone replacement graft for ridge preservation. You say that you would like the 
Plan to pay for this. The Plan denied your request. The Plan says the rendered dental service is not a covered 
dental benefit. 
 
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 a bone 
replacement graft for ridge preservation (D7953) provided by an out-of-network provider on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
December 22, 2021. 
 You asked the Plan to pay for the laboratory service. You say that this letter documents the medical necessity 
of the test requested for the enrollee to assist in treatment selection for their cancer. The Plan denied your 
request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we find that CPT code 81479 is not supported in the medical record. Specifically, Medicare denies 
coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel. Additionally, modifiers should not be used to report multiple codes when a single 
specimen is tested. The medical records provided do not show that the service billed with the -59 modifier is a 
distinct procedural service. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted 
molecular pathology procedure (81479) provided December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on July 20, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility (SNF) care. You say that you weren't able to receive 
services from an in-network provider. 
 
 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 skilled nursing facility (SNF) care provided on 
July 20, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for brachytherapy provided on February 8, 
2022. 
 
You asked the Plan to waive the coinsurance for brachytherapy. You say that this charge should be covered. 
The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for each Medicare-covered medical supply.  
 
You have been asked to pay $820.29 which is 20% of the allowed amount for brachytherapy. The allowed 
amount is $4,101,50(20% x $4,101.50= $820.29). Brachytherapy source, non -stranded, cesium-131 is a 
medical supply which falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
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 coinsurance for brachytherapy provided on 
February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on August 6, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that the Plan insurance information was 
not presented by the patient, so you were unable to contact the Plan office to obtain an authorization or submit 
the claim timely. The Plan denied your request. The Plan says this provider is not a network provider with the 
Plan. The Plan also says that they have also determined that these services are 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 a hospital outpatient clinic visit provided on 
August 6, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you for COVID-19 at home test purchased on January 6, 2022. 
 
You asked the Plan to reimburse you for COVID-19 at home test. You say that you purchased a COVID-19 
self-test because you could not schedule a test within a reasonable time. The Plan denied your request. The 
Plan says that this is prior to the January 15, 2022, date on which the Plan started providing coverage for such 
purchases. 
 
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. The plan did not submit documentation that shows coverage for home tests had 
not begun at the time the test was purchased. In addition. the enrollee was informed the home test would be 
covered. Therefore, we decided that the Plan has to reimburse you for COVID-19 at home test provided on 
January 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six acupuncture treatments. 
 
You asked the Plan to pre-approve the treatments. You say that these therapies help keep the pain at bay. The 
Plan denied your request. The Plan says the records provided are not with the range for the dates of the 
requested treatment. 
 
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, this is not being requested for chronic lower back pain. This is being requested for abdominal pain/discomfort from irritable bowel syndrome. Therefore, we 
decided that the Plan does not have to pre-approve six acupuncture treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids you purchased from a non-plan vendor on 
June 23, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you called the Plan and were directed to this 
provider. The Plan denied your request. The Plan says in August of 2020, you called and inquired about your 
hearing benefit.  You were given an appointment for a hearing exam with this non-plan vendor, but you were 
not advised you could purchase hearing aids from them.  Hearing aids purchased from non-plan vendors are not 
covered. 
 
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 only when purchased from the Plan's designated hearing vendor.  You did not use the Plan's 
designated hearing vendor for these hearing aids. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids you purchased on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
December 23, 2021. 
 
You asked the Plan to pay for FoundationOne CDx test. You say that the provision of F1CDx meets the 
requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says this service does not meet 
Medicare NCD/LCD criteria. 
 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 next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of FoundationOne CDx test have not 
been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis. 
 
You asked the Plan to pre-approve the requested orthosis. The Plan denied your request. The Plan says you do 
not have recent injury or evidence of instability. The Plan follows Medicare rules. Medicare rules say that knee orthoses are only covered under certain medical 
indications.  
 
The file shows that a custom fabricated knee orthosis (L1844) was requested. 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 requested orthosis. Our physician reviewer found you have severe knee 
pain as a result of unilateral primary osteoarthritis of the left knee. The documentation in the case file does not 
support that you have an objective description of joint laxity or have physical characteristic(s) which requires 
the use of a custom fabricated orthosis. 
 
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 requested orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a knee orthosis.