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

 
We decided that the Plan does not have to pay for the psychiatric evaluation provided on February 22, 2023. 
 
You asked the Plan to pay for the psychiatric evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all of their patients. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the psychiatric 
evaluation provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transportation service. 
 
You asked the Plan to pre-approve the transportation service. You say that you have extractions scheduled at a 
provider more than 35 miles outside the Plan's service area. You say the extractions are already approved and 
you are in pain and can no longer wait. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation within plan-approved locations in the plan service area.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the providers office 
is not within the Plans service area. Therefore, we decided that the Plan does not have to pre-approve the 
transportation service.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care services provided on April 24, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for vision care. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan and 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 covers out-of-network services through a Point of Service (POS) option; however, 
authorization must be obtained from the Plan prior to seeking out-of-network 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 vision care services provided on April 24, 2023, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
(K0856) and related items (E0955, E1002, E1012, E1028, E2311, E2361, and E2603). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with single power option and other related 
items. You say that the enrollee is not able to shift weight. You say that the enrollee is non-ambulatory and 
therefore will need a tilting chair and pressure relief cushion.  The Plan denied your request. The Plan says the 
notes do not show the enrollee has a medical need for the requested power tilt and recline. The Plan says there 
is not a medical need to control more than two power options though the joystick. The Plan also says that 
power leg lifts are not medically needed.  
 
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 group 3 power wheelchair with 
single power option and other related items. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a stroke in 
2016. She is non-ambulatory and requires a lift to stand. The enrollee has been using a power wheelchair for 
over 5 years. She does not have skin breakdown, use a catheter, or have spasticity impacting her positioning. 
The enrollee does not require an alternative means of managing power drive.  
 
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 group 3 power wheelchair with single power option and other related items 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair with single power option (K0856) and related items (E0955, E1002, E1012, E1028, E2311, E2361, 
and E2603).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (83520, 87177, 87209, 82274, 83631, 87338, 
87798, 83993, 82656 and 82705) provided on April 20, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that these services are included in the 
facility services for the billed date of service and cannot be separately reimbursed. In addition, these services 
were not reported appropriately. 
 
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, the Plan has provided no evidence or documentation of any other 
facility where the enrollee was admitted, that billed these same services, or that has already received payment 
for these services. The Plan has provided a blanket statement indicating that these codes were inappropriately 
reported as separate services but has not provided a clear citation to support this argument. The Plans denial is 
not substantiated in this case. Therefore, we decided that the Plan has to pay for laboratory services (83520, 
87177, 87209, 82274, 83631, 87338, 87798, 83993, 82656 and 82705) provided on April 20, 2023.  
 
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 pay for the home visit provided on March 22, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV). 
 
You asked the Plan to pre-approve POV. You say that this equipment is medically necessary. The Plan denied 
your request. The Plan says the record does not show that you have difficulty with MRADLs nor does it 
include a home assessment. 
 
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 POV. Our reviewer says that you do not meet criteria for a POV. Our physician reviewer found the record does not support that you require this device 
to perform MRADLs in the home or that your home can accommodate the device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation and management provided on 
February 06, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for home visit for evaluation and management. You say that you are requesting 
reconsideration asking for the medical records to be reviewed. The Plan denied your request. The Plan says the 
enrollee must receive their care from a network provider (for more information about this, see Section 2 of 
Chapter 3). In most cases, care the enrollee receives from an out-of-network provider (a provider who is not 
part of the plans network) will not be covered.  
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 home visit for evaluation and management 
provided on February 06, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861) and related items (E2361, E1028x2, E2377, E2313, E1007, E0955, E2311, E2624, E2620, 
E1012, E0956, and E0957). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options and other related 
items. You say that the enrollee meets the medical necessity per the coverage guidelines.  The Plan denied your 
request. The Plan says the notes do not show that the enrollee is able to operate the power wheelchair safely. 
The Plan also says that the notes do not show that the enrollee's caregiver cannot use manual wheelchair that 
has been set up for their needs.  
 
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 group 3 power wheelchair with 
multiple power options and other related items. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have high 
risk for skin breakdown, does not use a catheter intermittently, and does not have spasticity. The enrollee does 
not require an alternative means of managing power drive. The enrollee has a minor skin issue and is 16-
months post-stroke.  
 
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 group 3 power wheelchair with multiple power options and other related 
items have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair with multiple power options (K0861) and related items (E2361, E1028x2, E2377, E2313, E1007, 
E0955, E2311, E2624, E2620, E1012, E0956, and E0957).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 01, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not agree with the 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for each one-way Medicare-covered ground ambulance transport. 
 
You have been asked to pay a $275 copayment for ambulance services. This item/service falls within the each 
one-way Medicare-covered ground ambulance transport 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 ambulance services provided on March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on April 10, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent transportation by taxi. 
 
You asked the Plan to pre-approve non-emergent transportation. You say that you have an annual medical 
appointment to attend in order to continue getting prescriptions filled. The Plan denied your request. The Plan 
says non-emergency transportation by taxi is not a covered service under your plan. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of non-emergent transportation have not been met. Specifically, the EOC 
confirms that non-emergency transportation by ambulance is appropriate if it is documented that your condition 
is such that other means of transportation could endanger your health and that transportation by ambulance is 
medically required. The records show that you have an annual medical appointment which is not considered a 
medical emergency. Therefore, we decided that the Plan does not have to pre-approve non-emergent 
transportation by taxi.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  the ambulance services.  
 
You asked the Plan to waive the copayment for  the ambulance services. You say that you are getting charged 
the wrong amount every time you use this service. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $290 
copayment for each ambulance trip. You had 2 ambulance trip(s). The Plan charged you $580 for these 
services. 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 ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve InnovaMatrix AC, per square (sq) centimeter (cm) 
(A2001), Axolotl Graft or Axolotl DualGraft, per sq cm (Q4210) and Celera Dual Layer or Celera Dual 
Membrane (Q4259). 
 
You asked the Plan to pre-approve wound care. You say that the enrollee meets medical policy criteria and 
desperately needs this skin graft to assist with the healing of the ulcer and ultimately improve his quality of life. 
The Plan denied your request. The Plan says the records do not show review of the enrollee's blood sugars or 
nutritional status. 
 
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 wound care. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a non-healing skin ulcer and is requesting concurrent skin substitutes. 
Documentation does not support that the request for concurrent skin substitutes is medically necessary or 
appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve InnovaMatrix AC, per square (sq) centimeter (cm) (A2001), Axolotl Graft or Axolotl 
DualGraft, per sq cm (Q4210) and Celera Dual Layer or Celera Dual Membrane (Q4259).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve home health. You say that the enrollee needs help on a daily basis. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can receive 
care within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health care to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior vertebral joint arthroplasty, including 
facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when 
performed, including fluoroscopy, single level, lumbar spine (0202T). 
 
You asked the Plan to pre-approve a total posterior arthroplasty system (TOPS) implant. You say that the time 
and intensity to complete the entire implant procedure, is substantially equivalent to that required to perform 
the more traditional posterior decompression and spinal fusion procedure. The Plan denied your request. The 
Plan says the requested service is experimental in nature and is not covered by the Plan. 
 
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 total posterior arthroplasty system 
(TOPS) implant. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the TOPS device is experimental and investigational. 
There is more research needed to show efficacy. 
 
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 total posterior arthroplasty system (TOPS) implant have not been met. 
Therefore, we decided that the Plan does not have to pre-approve posterior vertebral joint arthroplasty, 
including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, 
when performed, including fluoroscopy, single level, lumbar spine (0202T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan and the laboratory services provided on February 
8, 2023, by an OON provider.  
 
You asked the Plan to pay for a CT scan and the lab services. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says this service was 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 CT scan and the laboratory services provided on 
February 8, 2023, by an OON provider.