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

 
We decided that the Plan does not have to pre-approve a heavy-duty wheeled walker with seat attachment and 
hand brakes (E0149, E0156, A9270). 
 
You asked the Plan to pre-approve a heavy-duty wheeled walker with seat attachment and hand brakes. You 
say that you weigh 260 pounds and not 300 pounds. Your weight is concentrated in your hip and abdomen area, 
and you need something to sit on when your lower back becomes painful from standing. The Plan denied your 
request. The Plan says you do not meet coverage criteria for the requested heavy-duty walker. 
 The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for beneficiaries 
who meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. The records show that you do not weigh more than 300 pounds. 
Based on this information, we decided that Medicare rules for coverage of a heavy-duty wheeled walker with 
seat attachment and hand brakes have not been met. Therefore, we decided that the Plan does not have to pre-
approve a heavy-duty wheeled walker with seat attachment and hand brakes (E0149, E0156, A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision therapy services (E1399) provided March 22, 
2022. 
 
You asked the Plan to pay for the vision therapy. You say that you personally submitted 8 pages of doctor's 
records justifying diagnosis with extensive testing and a plan of treatment. The Plan denied your request. The Plan says this treatment does not meet Medicare's definition of DME as it was used in the doctors office and is 
not appropriate for use in the home. Vision therapy is excluded by the Plan. 
 
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. Routine eye examinations, eyeglasses, radial keratotomy, LASIK surgery, vision therapy and other 
low vision aids are not covered by Medicare. The Plan only eye exams and one pair of eyeglasses or contact 
lenses are covered for people after cataract surgery. 
 
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 vision therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
the vision therapy services (E1399) provided March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment of and care planning for a patient with cognitive 
impairment provided on April 14, 2022. 
 
You asked the Plan to pay for assessment of and care planning for a patient with cognitive impairment. The 
Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers 
require prior authorization. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for assessment of and care planning for a patient with cognitive 
impairment provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 25, 
2022, by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says the 
out-of-network services were not authorized.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
February 25, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a cone beam CT 
capture (D0367) provided by a participating provider on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like this should be paid. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows D0140 was exhausted on date of service May 31, 2022. D0367 is not a covered benefit. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a cone beam CT capture 
(D0367) provided by a participating provider on July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nitro Drive rollator walker. 
 
You asked the Plan to pre-approve a Nitro Drive rollator walker. You say that this is medically necessary for 
the mountainous area you live in as your current walker cannot be used outside. The Plan denied your request. 
The Plan says Medicare and Plan criteria have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is specifically being requested for use outside of the home. Although this item 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pre-approve a Nitro Drive rollator walker.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic procedures and tests provided on 
June 08, 2022. 
 
You asked the Plan to waive the copayment for diagnostic procedures and tests. You say that you shouldnt 
have to pay any charges. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $28.46 
copayment for Diagnostic procedures and tests in a specialists office. 
 
You have been asked to pay a $28.46 copayment for diagnostic procedures and tests. This item/service falls 
within the Diagnostic procedures and tests in a specialists office 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. You have been asked to pay $28.46 which is less 
than the standard $30 copayment for diagnostic procedures and tests in a specialists office. Therefore, we 
decided that the Plan does not have to waive the copayment for diagnostic procedures and tests provided on 
June 08, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 27, 2021 to March 9, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $325 
copayment per day for days 1-6 of Inpatient hospital care.  
 
 
  You have been asked to pay a $650 copayment for 2 days of inpatient hospital care. This item/service falls 
within the Inpatient hospital care 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 
inpatient hospital care provided from February 27, 2021 to March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on May 10, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration because there was no 
payment on this claim. The Plan denied your request. The Plan says the enrollees network primary care 
physician (PCP) or plan must give the enrollee approval in advance before they can use providers not in the 
plan's network. This is called giving you a "referral." 
 
 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 injections provided on May 10, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for podiatry services provided on July 08, 2022. 
 
You asked the Plan to waive the deductible for podiatry services. You say that with the exuberant cost, you will 
not get the care you need. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 
$237.67 deductible for Podiatry services. 
 
You have been asked to pay a $237.67 deductible for podiatry services. This item/service falls within the 
Podiatry 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 deductible for podiatry services 
provided on July 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on June 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no approved authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound care services provided on June 20, 
2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service July 3, 2022. 
 
You asked the Plan to pay for procedure code 99284. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99284 billed for date of service July 3, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on May 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimens to 
your laboratory to process. The Plan denied your request. The Plan says that the rendering provider is an OON 
provider and there was no approved authorization. 
 
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 claim information submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is also out-of-network. Therefore, we decided 
that the Plan has to pay for the laboratory services provided on May 5, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from April 5, 2022, to  
April 26, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says this type of provider is not part of the Medicare Program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from 
April 5, 2022, to April 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency ambulance transportation (A0429) and ground 
mileage (A0425) provided on October 19, 2021. 
 
You asked the Plan to pay for emergency ambulance transportation and ground mileage. You say that the claim 
is not a duplicate and payment should be processed. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 22, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for emergency ambulance transportation and 
ground mileage have not been met. Therefore, we decided that the Plan does not have to pay for emergency 
ambulance transportation (A0429) and ground mileage (A0425) provided on October 19, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services provided on June 9, 2022. 
 
You asked the Plan to pay for therapy services. You say that you disagree with the denial of therapy services. 
The Plan denied your request. The Plan says that the provider is not eligible to perform the services billed. 
 
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 has not supported their decision to deny your request. Therefore, we 
decided that the Plan has to pay for physical therapy services provided on June 9, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 27, 2020, to 
September 9, 2020, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for payment at the DRG originally billed have not been met. 
 
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.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.02, defined as "Sepsis 
due to Methicillin resistant Staphylococcus aureus," and secondary diagnosis code R65.20, defined as "Severe 
sepsis without septic shock." 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the inpatient hospital services at issue do 
not meet criteria for payment at the DRG originally billed. Our physician reviewer found that the available 
medical records do not support principal diagnosis A41.02 and secondary diagnosis R65.20.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 27, 2020, to September 9, 2020, at the DRG originally 
billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5050) provided April 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that OON services are covered with a higher cost-
sharing. The Plan denied your request. The Plan says this service is not covered because it was provided OON. 
 
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 provided OON only when prior authorization is obtained.  
 
We looked at the file and the Plan's rules. In this case the hearing aids were provided OON without prior 
authorization. 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 (V5050) provided 
April 25, 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 a telephone evaluation (99441) provided on March 2, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telephone evaluation. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and 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 a telephone evaluation (99441) provided on March 
2, 2022 by an out-of-network (OON) provider.