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

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you need this item for your 
wheelchair. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that  power seat elevation features are not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that you are requesting a power seat 
elevation system. This item is specifically not covered. Based on this information, we decided that Medicare 
rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevation system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 11, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services should be covered. The Plan 
denied your request. The Plan says you did not timely file your claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until March 25, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical services provided on March 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on February 2, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you said that the ambulance 
staff told you that your condition was not bad enough to transport you to the hospital.  You said that they 
refused to transport you, so this should be covered. The Plan denied your request. The Plan says non-transport 
ambulance services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The ambulance company did not provide transport services on February 2, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. This rule applies regardless of who makes the decision to not transport you. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services provided on 
February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on April 
15, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care (99308) provided 
on April 15, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient mental health services provided to the enrollee from February 
6, 2022, to February 27, 2022. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that the services were provided in 
good faith due to medical necessity. The Plan denied your request. The Plan says that no prior authorization 
was obtained prior to rendering the services. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospital services. Our 
reviewer says that the services at issue in this case were medically reasonable and necessary. Our physician 
reviewer found that based on the records provided, it was expected that this enrollee would improve in a 
reasonable period of time. Although she did not have dangerousness to self or others, the enrollee was found to 
be floridly psychotic. It did appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care. The enrollee was hyperverbal and difficult to 
redirect. It did appear that active treatment was taking place. The health plans denial of inpatient psychiatric 
services appears inappropriate. It did appear that the services were reasonably expected to improve the patients 
condition or for the purpose of diagnosis. 
 
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 psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient mental health services provided to the enrollee from February 6, 2022, to 
February 27, 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 copayment for office visit on March 29, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you should not have been charged a 
copayment because you were at the office that day for the 6-week post op visit included in a global package 
following surgery. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $40 
copayment for each specialist office visit for Medicare-covered services. Covered services include 
consultation, diagnosis, and treatment by specialist.  
 
 
 
 
 You have been asked to pay a $40 copayment for office visit. Office visits fall 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 waive the copayment 
for office visit on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99336) provided on March 23, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. 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 rest home visit (99336) provided on March 23, 
2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (93702). 
 
You asked the Plan to pre-approve the bioimpedance spectroscopy. You say that the bioimpedance 
spectroscopy is medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
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 bioimpedance spectroscopy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found current guidelines do not advocate for use of bioimpedance spectroscopy but 
rather a symptoms based approach to early diagnosis of lymphedema, which is more sensitive than 
bioimpedance spectroscopy. 
 
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 bioimpedance spectroscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bioimpedance spectroscopy (93702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that Evenity is medically necessary. The Plan denied your 
request. The Plan says a trial of Forteo is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Evenity. Our reviewer says that Evenity 
is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or 
any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on 
February 11, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care (99309) provided 
on February 11, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement provided to the 
enrollee on October 1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 14301-78 is not supported by the medical records submitted. 
 
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 14301 is "Adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report does not 
describe a flap of healthy skin relocated from a donor site to an adjacent laceration, scar or other discontinuity, 
with a portion of the flap left intact to supply blood to the grafted area. In this case this procedure code cannot 
be verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for adjacent tissue transfer or rearrangement provided to the enrollee on October 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator. 
 
You asked the Plan to pre-approve the nerve stimulator. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this procedure is not medically necessary for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Electrical Nerve Stimulation (PENS) is 
a diagnostic procedure which involves stimulation of peripheral nerves by a needle electrode inserted through 
the skin. It is performed only in a physician's office, clinic, or hospital outpatient department. Therefore, it is 
covered only when performed by a physician or incident to physician's service. If pain is effectively controlled 
by percutaneous stimulation, implantation of electrodes is warranted. 
 
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 nerve stimulator. Our reviewer says 
that this service is not medically necessary. Our physician reviewer found this procedure would be considered 
experimental or investigational for the treatment of Complex Regional Pain Syndrome.  
 
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 nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin graft (15734). 
 
You asked the Plan to pre-approve the skin graft. You say that this procedure is not medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 skin graft. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of skin graft is not considered a standard component of laparoscopic hiatal hernia 
repair. It is not supported by published literature. 
 
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 skin graft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skin graft (15734).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatry services you received on November 8, 2021. 
 
You asked the Plan to pay for the psychiatry services. You say that you have a long relationship with this 
provider and do not wish to find a new one. The Plan denied your request. The Plan says services with this 
provider are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychiatry 
services you received on November 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided to the 
enrollee on December 11, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance was 
medically necessary. The Plan denied your request. The Plan says the enrollee was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment for each one-way ground ambulance trip.  
 
The enrollee was asked to pay a $325 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services benefit category. This means that the enrollee was asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for ambulance transportation provided to the enrollee on December 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve a replacement CPAP device. You say that you cannot find your device. The 
Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement CPAP devices are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. The documentation does not include notes that state you are 
benefiting from and using your current CPAP. While the documentation shows that you have lost your previous 
device, the documentation does not include documentation showing whether your machine was more or less 
than five years old. Without this documentation, a new device cannot be approved. Based on this information, 
we decided that Medicare rules for coverage of a replacement CPAP device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) 
device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 18, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 an office visit provided on February 18, 2022 by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan of the lower extremity 
arteries you had on March 7, 2022. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that you have never had a copayment 
for this service before because you only see the cardiology technician. The Plan denied your request. The Plan 
says you were charged this copayment 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 $25 
copayment for outpatient diagnostic tests and imaging services you receive in a specialist's office.  
 
You have been asked to pay a $25 copayment for the duplex scan. The duplex scan falls within the outpatient 
diagnostic tests and imaging services you receive in a specialist's office benefit category. This copayment 
applies to all advanced imaging services you receive in a specialist's office, regardless of whether or not you 
see the doctor during the visit. 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 duplex scan of the 
lower extremity arteries you had on March 7, 2022.