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

 
We decided that the Plan does not have to pay for subsequent nursing facility care services provided on August 
9, 2022.   
 You asked the Plan to pay for the subsequent nursing facility care services. The Plan denied your request. The 
Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 5, 2022. The services in question were provided 
before the end of that month.  Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care services provided on August 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that this should be covered. The Plan 
denied your request. The Plan says neither Medicare nor the Plan cover this request. Medical studies haven't 
proven this service/item is helpful for the treatment of your health problem. 
 
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 a Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. 
 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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo system (0266T, C1825).
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 you are appealing this denial. The Plan denied your 
request. The Plan says the denial of IRF care is correct. 
 
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.  Our 
physician reviewer found the enrollee is medically stable and does not need rehabilitation physician 
supervision at least 3 times per week. While the enrollee may benefit from physical and/or occupational 
therapy, the enrollee's rehabilitation needs can be provided in a lower intensity alternate setting such as a 
skilled nursing facility. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service August 19, 
2022, to September 17, 2022. You asked the Plan to pay for the billed services. You say that the first NOA was rejected for missing 
information. The Plan denied your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 19, 2022. A valid NOA was not received by the Plan until 
December 15, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health care billed for dates of service August 19, 2022, to September 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialized lower limb prosthetic cover (L5964). 
 
You asked the Plan to pre-approve a specialized lower limb prosthetic cover. 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 protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a 
beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, 
L5706, and L5707.  
 
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 specialized lower limb prosthetic 
cover. Our reviewer says that this item is not medically necessary. Our physician reviewer found the documentation does not support that the member requires a specialized outer covering system or that he is 
exposed to a harsh environment. 
 
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 specialized lower limb prosthetic cover have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a specialized lower limb prosthetic cover (L5964).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diagnostic colonoscopy provided on 
January 25, 2023 
 
You asked the Plan to waive the deductible for diagnostic colonoscopy. You say that you are disputing the 
share cost. 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 $497.55 
deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay $497.55 deductible for diagnostic colonoscopy. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 diagnostic colonoscopy provided 
on January 25, 2023
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation provided on October 31, 2022. 
 You asked the Plan to pay for the blood smear interpretation. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the blood smear interpretation provided on October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ambulatory surgical boot (L3260). 
 
You asked the Plan to pre-approve the ambulatory surgical boot. You say that you are appealing the denial of 
the boot because you were told you needed to get it from an Orthopedist for approval. You also say that you 
did this. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition.  Additionally, Medicare rules say that with the exception of the situations described, orthopedic 
footwear billed using code L3260 will be denied as non-covered. Therefore, we decided that the Plan does not have to pre-approve the ambulatory surgical boot (L3260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on June 22, 2022. 
 You asked the Plan to pay for subsequent hospital care. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital care provided on June 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlimited non-emergency transportation trips (A0100). 
 
You asked the Plan to pre-approve the unlimited non-emergency transportation trips. You say that you are 
requesting unlimited transportation to various medical scheduled appointments. The Plan denied your request. The Plan says you have used 23 of the 24 rides, leaving you with 1 remaining 
trip. 
 
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 24 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 unlimited non-emergency transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 87507 for date of service 
January 18, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 87507 
for date of service January 18, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve additional non-emergency transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that the patient 
receives life sustaining dialysis treatments 3 times a week and is considered immunocompromised and is part 
of the high-risk population due to their end stage renal disease diagnosis. The Plan denied your request. The 
Plan says that the enrollee has already used the 24 transportation trips covered by the Plan. 
 
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. Specifically, we attempted to collect this information from the Plan but did not 
receive the necessary documentation in response Therefore, we decided that the Plan has to pre-approve 
additional non-emergency transportation trips (A0100).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an OON provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have gone to this dentist before and 
liked her and would like to go again. The Plan denied your request. The Plan says dental services from an out-
of-network provider are not covered by your supplemental benefits.  
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider.  Therefore, we decided that the Plan does not have to pre-approve dental 
services provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that you have limited 
mobility and can no longer use a cane or walker because you do not have the strength in your legs. You also 
say that having a scooter is prudent in maintaining your daily activities. The Plan denied your request. The Plan 
says you do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 1 standard power operated 
vehicle. Our reviewer says that you do not meet the criteria for a group 1 standard power operated vehicle. Our 
physician reviewer found you are independent in transfers and are able to walk 100 feet. Our reviewer also 
found that you have the capacity to manage your MRADLs in the home. 
 
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 group 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership provided from 
January 1, 2023, through April 1, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the membership purchased in this 
case is not a covered benefit. Specifically, the Plans contract states that coverage is provided for a fitness 
membership through the Plans select fitness provider.  
  
 
However, in this case, you purchased a gym membership from an out-of-network provider. Additionally, the 
Plans contract states that enrollees receive $275 every three months on a Flex card that may be utilized for 
qualifying fitness expenses that includes fitness centers, gyms, and athletic clubs. Therefore, we decided that 
the Plan does not have to issue reimbursement for the health club membership provided from January 1, 2023, 
through April 1, 2023.
Appeal type: Step-Therapy
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 the enrollee needs to start treatment right away. The 
Plan denied your request. The Plan says the enrollee does not have any stated contraindications to and has not 
tried any of the preferred agents. The Plan also says a rationale was not provided for use of the non-preferred 
product for safety or efficacy. 
 
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 the 
enrollee does not meet the coverage criteria for Evenity. Our physician reviewer found the enrollee has not 
tried and failed the required drugs. Our reviewer also found that there is no documentation provided indicating 
that the Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted special service. 
 
You asked the Plan to pre-approve the unlisted special service . You say that you were not advised that you 
would need to call in for a catalog. You say you would like your $145 allowance. The Plan denied your 
request. The Plan says the over-the-counter benefit allowance per quarter cannot be carried over to another 
quarter. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC drug allowance benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested services is not covered 
because the $145 allowance cannot be carried over to another quarter. Therefore, we decided that the Plan does 
not have to pre-approve the unlisted special service.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the correct place of service was billed. The Plan 
denied your request. The Plan says code 99153 is not payable in the facility setting.  
 The Plan follows Medicare rules. Medicare rules say that PE only codes are not payable to the physician for 
services provided in the facility setting.  
 
The file shows that the services at issue were provided in an outpatient hospital facility. We find that payment 
for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 
99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for 
procedure code 99153 billed for date of service November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visit provided on 
January 6, 2023. 
 
You asked the Plan to waive the deductible for the specialist office visit. You say that you should only have an 
$18 copayment. 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. Your 
contract with the Plan says that there is a $233 deductible which applies to specialist office visits. Your contract 
with the Plan also says that you must pay an $18 copayment after meeting the deductible for each specialist 
office visit. 
 
You have been asked to pay $213.06 towards the deductible. The item or service you asked the Plan to waive 
the deductible for falls within the physician/practitioner services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $233 deductible which applies to specialist 
office visits. This cost sharing is a contractual obligation that had not been met at the time the specialist office 
visit was received on January 6, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for the specialist office visit provided on January 6, 2023.