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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that you need additional transportation to get your 
appointments on Mondays, Wednesdays, and Fridays. The Plan denied your request. The Plan says additional 
transportation is not a covered benefit. 
 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 a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair leg lifts (K0739). 
 
You asked the Plan to pre-approve the power wheelchair leg lifts. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Elevating legrests are covered if the criteria listed in 
the Medicare Rules section are met. 
 
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 power wheelchair leg lifts. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found you do not have a  
musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or  
significant edema of the lower extremities that requires an elevating legrest; or meet the criteria for and has a 
reclining back on your 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 the power wheelchair leg lifts have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the power wheelchair leg lifts (K0739).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the diagnostic testing provided on February 7, 2022. 
 
You asked the Plan to pay for the diagnostic testing. You say that you would like the claim to be reprocessed 
for payment with the authorization on file. The Plan denied your request. The Plan says that the rendering 
provider is an OON provider, and the precertification entity was not contacted for precertification. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the diagnostic testing by a contract provider. The file does not show that the plan 
provided notice that the diagnostic testing would not be covered. Under Medicare rules, this means the 
diagnostic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
diagnostic testing provided on February 7, 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 waive the coinsurance for an intravenous (IV) injection provided on 
May 21, 2021. 
 
You asked the Plan to waive the coinsurance for an IV injection. You say that you have a $0 copayment for lab 
services. 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for IV therapy or transfusion services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$39.80, which is less than 20% coinsurance of the allowed amount for an IV injection. An IV injection falls 
within the Outpatient Hospital 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 coinsurance 
for an intravenous (IV) injection provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nutritional therapy (99213). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this is not a covered service for your diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve the nutritional therapy (99213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (K0800) and lead 
battery (E2365). 
 
You asked the Plan to pre-approve a POV and battery. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for a POV to be covered, all the criteria listed in the 
Medicare Rules section must be met. 
 
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 POV and battery. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found the documentation doesn't support that 
the member requires a power mobility device to be able to accomplish mobility related self-care tasks in the 
home or that there is space in the home for use of a POV. 
 
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 POV and battery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power operated vehicle (POV) (K0800) and lead battery (E2365).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper extremity external stimulator of the peripheral 
nerves. 
 
You asked the Plan to pre-approve the requested item. You say that reductions in tremor severity leads to 
significant improvements in daily activities. The Plan denied your request. The Plan says this device is not the 
standard of practice for the treatment of an essential tremor. 
 
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 requested item. Our physician 
reviewer found that the enrollee has essential tremors in both hands, jaw, head, voice. She is having difficulty 
with activities of daily living. She takes Propranolol and Primidone medications for the condition. Per the 
literature, the effectiveness of this device is not established for the treatment of essential and Parkinsonian 
tremor. Medical necessity has not been as Medicare does not pay for any items or services that are not 
reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. The requested device is not proven to have long term effectiveness for the enrollees 
condition. Therefore, the request is 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 requested item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an upper extremity external stimulator of the peripheral nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on 
February 15, 2022. 
 
You asked the Plan to reduce the copayment for the office visit. You say that you only saw a nurse practitioner. 
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). Your contract with the Plan clearly says that you must pay a $40 
copayment for each specialist visit.  
 
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 reduce the copayment for a specialist office visit provided on February 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (93005) provided on 
November 12, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $90 
copayment for diagnostic procedures and tests at an outpatient hospital setting.  
 
You have been asked to pay a $90 copayment for the diagnostic test provided in an outpatient hospital setting. 
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 the electrocardiogram (93005) provided on 
November 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for your routine transportation. 
 
You asked the Plan to pre-approve additional miles. You say that you need a prescription because you are 
experiencing severe pain. The Plan denied your request. The Plan says your benefit only allows 50 miles. 
 
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.  
 
 
 Routine transportation over 50 miles was requested. We looked at your request, the records in the case file, and 
the rules. Your plan benefit only covers routine transportation for up to 50 miles. 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 additional mileage for your routine transportation.
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. The Plan denied your request. The Plan says your needs can be 
addressed at a lower 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 physician reviewer found 
that you were admitted to the acute care hospital for syncope and a vertebral compression fracture. Your 
medical problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation 
therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that the enrollee requires surgery to be 
done and only the OON provider can perform the surgery. The enrollee spoke with an in-network provider, and 
they cannot perform the necessary treatment that the enrollee needs. Therefore, the enrollee would like to see 
an OON provider. The Plan denied your request. The Plan says there are 2 in-network providers available to 
perform a second opinion evaluation and all available in-network providers have not been tried. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 7, 2021, to 
March 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that you would like this claim reprocessed 
and paid. The Plan denied your request. The Plan says prior authorization was not 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 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 inpatient hospital services provided on March 7, 
2021, to March 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth service provided on January 5, 
2022. 
 
You asked the Plan to waive the copayment for the telehealth service. You say that you only called to get a 
prescription refilled and they billed it as a telephone visit. The Plan denied your request. The Plan says the 
appropriate copayment was applied for the service billed. 
 
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 $5 
copayment for each Medicare-covered primary care office visit including Some telehealth services including 
consultation, diagnosis, and treatment by a physician or practitioner.  
 
  You have been asked to pay a $5 copayment for the telehealth service. The telehealth service falls 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 a telehealth service provided on January 5, 2022.  
 
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided October 7, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99285 is Emergency Room visit for the evaluation and 
management of a patient. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the records provided do not 
support that the service involved medical decision making of a high complexity. Based on this information, we 
decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we 
decided that the Plan does not have to pay for emergency room services (99285) provided October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve dialysis. You say that the enrollee was seeing this provider while in the 
hospital. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan and the enrollee can receive dialysis from an in-network 
provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dialysis to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from August 30, 2021, to 
September 3, 2021, as billed with Diagnosis Related Group (DRG) 291. 
 
You asked the Plan to pay for inpatient care billed with DRG 291. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 291 is not appropriate as the diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in the medical 
record. The Plan argues that DRG 292 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
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 inpatient care billed with DRG 291. Our 
reviewer says that the diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in the 
medical record for this inpatient admission. Our physician reviewer found that the documentation supported an 
admission for congestive heart failure (CHF). Even though respiratory failure was documented, supporting 
medical record documentation was not found within the record. A life-threatening diagnosis of acute 
respiratory failure would include symptoms such as but not limited to: markedly low oxygenation, respiratory 
distress, labored breathing, tachypnea, altered mental status, accessory muscle use and arterial blood gasses 
(ABGs) consistent with the diagnosis. The enrollee presented as direct admit for shortness of breath and was 
found to have systolic congestive heart failure. There was no evidence of ABG or oxygen saturations (despite 
focused treatment being provided in the emergency department) to support this diagnosis. From the 
documentation received, there was no treatment consistent with acute respiratory failure or evidence of 
additional diagnostic testing such as arterial blood gases and no documentation of persistent impaired gas 
exchange and treatment consistent with acute respiratory failure. Although the provider documented respiratory 
failure, reasonable support within the health record must be present for that diagnosis. The review has 
determined that the medical records did not support the billing of acute respiratory failure with hypoxia 
(J96.01). 
 
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 care billed with DRG 291 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from August 30, 2021, to September 3, 
2021, as billed with Diagnosis Related Group (DRG) 291.