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

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on August 
07, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you shouldnt have to 
pay. 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 $230 
copayment for ambulance services. 
 
You have been asked to pay a $230 copayment for the ambulance services. This item/service falls within the 
ambulance 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 copayment for the ambulance 
services provided on August 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on August 07, 2023, to August 
28, 2023. 
 
You asked the Plan to pay for nursing facility visit. You say that this patient is in a facility, and you depend 
upon the facility staff for any verification or prior authorization. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 nursing facility visit provided on August 07, 2023, to August 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on July 24, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 wound care supplies provided on July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with code A4239 for June 24, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified as a 
durable medical equipment provider for the dates of service at issue. Therefore, we decided that the Plan does 
not have to pay for the supplies billed with code A4239 for June 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on September 22, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 wound care supplies provided on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for circulating cold pad with pump billed with code E0218 for 
date of service August 13, 2023, to September 1, 2023. 
 
You asked the Plan to pay for circulating cold pad with pump. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The item at issue (a fluid circulating cold pad with pump) is 
specifically not covered. Based on this information, we decided that Medicare rules for coverage of circulating 
cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pay for circulating 
cold pad with pump billed with code E0218 for date of service August 13, 2023, to September 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 26, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 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 pay for the pneumatic compression device provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel test billed for date of service 
September 25, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the documentation supports the requested test. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 The panel testing was billed using codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87563, 
87591, 87661, 87481, 87651, 87653, and G0452. We looked at the file and Medicare rules. The documentation 
supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, 
multiple methodologies, or multiple kits were used in this case. As such, a single code with one unit of service 
should be used. Based on this information, we decided that Medicare rules for coverage of the testing panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the urinary tract infection 
panel test billed for date of service September 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on August 17, 2023. 
 
You asked the Plan to waive the copayment for ER visit. You say that you were instructed to go to the ER so 
you shouldnt be charged. 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 $95 
copayment for Emergency care. 
 
You have been asked to pay a $95 copayment for ER visit. This item/service falls within the Emergency 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 ER visit provided on August 17, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression device (E0650) pneumatic 
appliances (E0673, E0666) and orthotics management and training (97760) provided on May 17, 2023, to June 
6, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the pneumatic compression device, appliances and orthotics training. You say 
that you are requesting reconsideration based on medical necessity for this enrollee and evidence based medical 
literature that substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 
pneumatic compression device (E0650) pneumatic appliances (E0673, E0666) and orthotics management and 
training (97760) provided on May 17, 2023, to June 6, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee still appears to be unstable and requires additional acute care services 
that can safely be provided at the current facility until more stable and appropriate for transfer. The enrollee 
does not require services at the LTACH that are not already available.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 25, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there was no authorization for the services provided. 
 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 had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 office visit provided on September 25, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 8, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 05, 2023. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 lab services provided on September 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service September 22, 
2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The file shows that the provided urinary tract infection panel was billed using codes 87500, 87641, 87798, 
87491, 87496, 87529, 87532, 87563, 87591, 87481, 87651, 87653, and G0452. We looked at the file and 
Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no 
evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a 
single code with one unit of service should be used. Based on this information, we decided that Medicare rules 
for coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay 
for the panel testing billed for date of service September 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a memory seat (K0108), bag hook (K0108), upgraded 
electronics (E2311, E2313, E2377), positioning belt (E0978), adjustable height panel (K0108), and cushion 
foam insert (K0108). 
 
You asked the Plan to pre-approve the accessories. You say that your current chair is working with problems. 
You say that the batteries drain really fast. You also say that the joystick is a loaner from the DME provider. 
The Plan denied your request. The Plan says the requested cushion foam is already included with the approved 
cushions. The Plan says that the armrests and seat belt are already included with the requested power 
wheelchair. The Plan says that these items cannot be covered separately. The Plan says that the bag hook and 
memory seat do not serve a medical purpose. The Plan also says that there is not a medical need to control 
power options through a joystick. 
 
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 upgraded electronics, positioning 
belt, adjustable height panel, and cushion foam insert. Our reviewer says that the requested upgraded 
electronics, positioning belt, adjustable height panel, and cushion foam inserts are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates that 
the enrollee has adequate strength to manage standard power drives. The reviewer found that the positioning 
belt is included with the approved power wheelchair. The reviewer also found that there is no evidence the 
elevated panel is medically necessary as the enrollee has functional range of motion in the upper 
extremities. Therefore, the reviewer found that  
 
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 upgraded electronics, positioning belt, adjustable height panel, and cushion 
foam insert have not been met. Additionally, the requested memory seat and bag hook do not serve a primarily 
medical purpose.  Therefore, we decided that the Plan does not have to pre-approve a memory seat (K0108), 
bag hook (K0108), upgraded electronics (E2311, E2313, E2377), positioning belt (E0978), adjustable height 
panel (K0108), and cushion foam insert (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on August 28, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
we have sent all the appropriate documents. The Plan denied your request. The Plan says that you are not 
enrolled in Medicare as a durable medical equipment supplier. Therefore, the claim was denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on August 
28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow 
aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition as discussed above. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the reviewer found that the requested bone marrow aspirate is not medically 
reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bone marrow aspirate.