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

 
We decided that the Plan does not have to pay for the autologous blood collection and storage (86891), special 
pump services (99190 and 99191) and washed white blood cells (P9022) provided on June 22, 2021. 
 
You asked the Plan to pay for the autologous blood collection and storage, special pump services and washed 
white blood cells. You say that you would like reconsideration based on the records submitted. The Plan denied 
your request. The Plan says payment for these services is included in the payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
 
  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the autologous blood collection and storage, special pump services and washed white blood cells 
have not been met. Specifically, the record suggests that the member was registered inpatient on the billed date 
of service. Payment for these services is included in the payment to the facility and is the responsibility of the 
facility to any vendor. Therefore, we decided that the Plan does not have to pay for the autologous blood 
collection and storage (86891), special pump services (99190 and 99191) and washed white blood cells 
(P9022) provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
September 7, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 out of network services provided to the enrollee on 
September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Gallium ga-68, dotatate, diagnostic
injection (A9587) provided on August 24, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the medical supply 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 20%
coinsurance for each Medicare-covered medical supply.
Supplies for which an appropriate separate charge is made by providers (such as, chemical agents used in
certain diagnostic procedures) are subject to cost-sharing.
You have been asked to pay $798.01 (Medicare allowable amount of $3,990.06 x 20% coinsurance) for the
Medicare-covered medical supply provided. 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 the
Gallium ga-68, dotatate, diagnostic injection (A9587) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the SPRINT PNS System (CPT code 64555). 
 
You asked the Plan to pre-approve the PNS system. You say that this was a covered benefit under the enrollee's 
plan. The Plan denied your request. The Plan says that this is not a covered benefit by Medicare for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 PNS system. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is a sixty (60) day implanted PNS device that is not permanent but has evidence to 
support its use for chronic pain as the effects can last even after removing the device after 60 days and can 
practically be compared to a permanent PNS device. Based on the current supportive evidence on this device 
and due to the enrollee having tried many first and second-line treatments for their chronic pain, the Sprint 
device will be considered reasonable and 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 PNS system have been met. Therefore, we decided that the Plan has to pre-
approve the SPRINT PNS System (CPT code 64555).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services and equipment.  
 
You asked the Plan to pay for these services and equipment. You say that this appeal process has been ongoing 
form months and the Plans departments do not speak to each other. You stated the equipment provided by the 
Plan was too heavy and you had to get the portable oxygen concentrator. The Plan denied your request. The 
Plan says you did not have prior authorization for out of network care and out of network equipment. 
 
 
 
  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
The providers in this case were 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 out of network services and equipment provided 
on February 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 3, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records 
provided do not show that the specimen was obtained at an independent laboratory. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the drug testing services provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment purchased on July 17, 2021.
You asked the Plan to pay for this equipment. You say that this equipment should be covered by the Plan. The
Plan denied your request. The Plan says you did not have prior authorization and the provider is not a Medicare
eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items provided by a vendor that is not a Medicare eligible provider. You purchased this equipment without
prior authorization from a provider who is not Medicare eligible. Therefore, we decided that the Plan does not
have to pay for durable medical equipment purchased on July 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
 
  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more components and for a positioning wedge. 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
components and for a positioning wedge. You say that the documentation provided supports the need for the 
items which remain in dispute. The Plan denied your request. The Plan says there is no medical need to control 
power options through the joystick. The Plan says that seat wedges are already included with the approved 
cushion and cannot be requested separately. 
 
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 an electronic connection between 
wheelchair controller and two or more components and for a positioning wedge. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested items exceed the enrollee's medical needs. The enrollee 
has 2 power options on the approved wheelchair but does not need to control the power options through a 
joystick. The enrollee's function with independence in feeding support that the enrollee can control any power 
options through their own switches. The K0108 lateral positioning wedge, large exceeds the enrollee's medical 
needs as the enrollee was approved for codes E2603 and E2620 and these cushions would include any items 
needed for proper function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection between wheelchair controller and two or more 
components and for a positioning wedge have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electronic connection between wheelchair controller and two or more components and for a 
positioning wedge.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cholestyramine Powder for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cholestyramine Powder for 
the enrollee.  
 Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
September 1, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network services provided to the enrollee on 
September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on August 24, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. You say that you were expecting to get reimbursed 
the difference from the amount you paid out of pocket and this copayment. You say that you purchased the 
hearing aids from a contracted vendor, and you were not aware there would be an exclusion to the benefit. The 
Plan denied your request. The Plan says a non-formulary pair of hearing aids was purchased. 
 
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.  
 
 
 
 
 
 
 We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, a non-formulary pair of hearing aids was 
purchased. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on 
August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for replacement eyeglass frames and lenses (V2020, V2200)
provided on August 5, 2021.
You asked the Plan to pay for replacement eyeglass frames and lenses. You say that your vision changed in less than 2 years and you required a new prescription. The Plan denied your request. The Plan says rules for payment for routine vision services have not been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $100 every 2 calendar years for any combination of eyeglasses with standard frames, contact lenses, and contact lens fitting. We looked at the file and the Plan's rules. In this case, you have exhausted the routine vision benefit within the past 2 years prior to the date of service. Based on this information, we decided that the Plan's rules for coverage of replacement eyeglass frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for replacement eyeglass frames and lenses (V2020, V2200) provided on August 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for ambulance transport provided on May 25, 2021.
You asked the Plan to waive this copayment. You say that you are unable to pay this bill. The Plan denied your request. The Plan says this cost share is a contractual obligation.
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 $350 copayment for ambulance transport. 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 charged for ambulance transport provided on May 25, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment charged for emergency room services provided 
on November 3, 2021. 
 
You asked the Plan to waive this copayment. You say that you were not happy with the care received and don't 
want to pay the copayment. The Plan denied your request. The Plan says this copayment is a contractual 
obligation. 
 
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 $110 for 
emergency room visits. 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 charged for emergency room services provided on 
November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided on September 30, 2021. 
 
You asked the Plan to pay for out of network services. . You say that the Plan should pay for these services 
because you were referred by the Plan. The Plan denied your request. The Plan says it was confirmed that you 
did not have a referral or prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 out of network services provided on September 
30, 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 these services are required to return to your baseline. 
The Plan denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The 
documentation does not support that you are reasonably expected to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the microfluidic analyses performed by a network provider on 
September 27, 2021. 
 
You asked the Plan to pay for the microfluidic analyses. You say that it was your understanding that the 
provider believed this to be medically necessary. The Plan denied your request. The Plan says that this is not 
covered according to Plan policy as it is not shown to be superior to other methods of testing. 
 
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. 
 
You were provided with the microfluidic analyses by a contract provider. The file does not show that the Plan 
provided notice that the microfluidic analyses would not be covered. Under Medicare rules, this means the 
microfluidic analyses is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
microfluidic analyses performed by a network provider on September 27, 2021.  
 
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.