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

 
We decided that the Plan does not have to pay for a home visit evaluation provided on March 20, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 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 a home visit evaluation 
provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
December 27, 2022, to December 30, 2022. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that this seems like a 
high amount for this service. Please verify and cover. 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 $295 
copayment per day, for days 1 to 5 for inpatient hospital services.  
 
You were in the hospital for 3 days, resulting in a $885 total copayment ($295 x 3 = $885). 
 You have been asked to pay an $885 total copayment for an in-network inpatient stay. This item/service falls 
within the inpatient hospital 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 
an in-network inpatient stay provided from December 27, 2022, to December 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast cancer index testing provided on February 15, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the breast cancer index testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the breast cancer index testing provided on February 15, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the continuous positive airway pressure (CPAP) 
device (E0601) purchased March 16, 2023. 
 
You asked the Plan to reimburse you for the CPAP device. You say that you were unable to wait to get a CPAP 
machine, so you ordered one online. You did not know that buying it would be a problem. The Plan denied 
your request. The Plan says the services was rendered by a provider who is not certified with Medicare. 
 
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 reimburse you for the continuous positive 
airway pressure (CPAP) device (E0601) purchased March 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the care would adversely affect the enrollee.  The 
Plan denied your request. The Plan says the records we received do not show that the enrollee needs complex 
daily care.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided May 3, 
2022, to June 1, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the service was correctly billed 
separately. These are not routine supplies. This DME should not be defined as an item included in the surgical 
facility fee. The Plan denied your request. The Plan says this is not included in coverage due to being 
prescribed for deep vein thrombosis (DVT) prophylaxis. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided May 3, 2022, to June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for walking boot on September 28, 2022. 
 
You asked the Plan to waive the coinsurance for walking boot. You say that you can afford this payment. 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 20% 
coinsurance for Medicare-covered benefits for durable medical equipment (DME). Covered items include, but 
are not limited to wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by 
a provider for use in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, 
and walkers. The provider billed in the amount of $506 and the allowed amount is $235.81 for the service. 
$235.81 x 20% = $47.16. The provider also billed in the amount of $90 and the allowed amount is $34.48 for 
the service. The plan paid $27.04 and there is a $0.55 sequestration. $34.48 - $27.04 = $7.44 - $0.55 = $6.89. 
For both, it's $47.16 + $6.89 = $54.05. Therefore, results in the total cost sharing amount of $54.05. 
 
You have been asked to pay a 20% coinsurance for walking boot. This item/service falls within the durable 
medical equipment (DME) and related supplies 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 
coinsurance for walking boot on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on March 01, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all 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 home visit for 
evaluation provided on March 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 12, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says these services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 12, 
2023, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on January 04, 2023. 
 
You asked the Plan to pay for an x-ray. 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 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 an x-ray provided on 
January 04, 2023.
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 the services are medically necessary due to the 
enrollee being at risk for further falls with injuries and neurological changes if not medically managed daily by 
a physician. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission 
to an IRF.  
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 very heavy-duty power operated vehicle 
(POV) with a patient weight capacity 451 to 600 pounds (K0808). 
 
You asked the Plan to pre-approve a group 2 very heavy-duty POV. You say that the enrollee does not need a 
motorized wheelchair. You also say that the enrollee needs an extra-large scooter with a swivel seat. The Plan 
denied your request. The Plan says this request is not medically necessary because the records show the 
enrollee does not meet the weight requirement that the Medicare guidelines outline. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that a POV is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the 
weight capacity of the next lower weight class POV. Medicare rules also say that if a group 2 POV, such as 
K0808, is provided it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 very heavy duty POV have not been met. Specifically, the provided records show that 
the enrollee's most recent documented weight is below the required weight limit of 451 to 600 pounds for the 
requested group 2 very heavy duty POV (K0808). Therefore, we decided that the Plan does not have to pre-
approve a group 2 very heavy-duty power operated vehicle (POV) with a patient weight capacity 451 to 600 
pounds (K0808).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial strain imaging, and the 
ultrasound of the heart provided on October 7, 2022. 
 
You asked the Plan to waive the copayment for the imaging and the ultrasound. You say that you think that 
these services should be covered. 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 $150 
copayment for Medicare-covered radiological diagnostic services, which includes ultrasounds, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $44.97 copayment for the imaging, and a $105.03 copayment for the ultrasound, 
which is a total copayment of $150. These items/services fall within the outpatient diagnostic tests and 
therapeutic services and supplies 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 myocardial strain imaging, and the ultrasound of the heart provided on October 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J1100, J2250, J2370, J2405, J2704, J3010, 
J7120, & D7140 provided on February 8, 2023. 
 
You asked the Plan to pay for procedure codes J1100, J2250, J2370, J2405, J2704, J3010, J7120, & D7140. 
You say that these services were medically necessary. The Plan denied your request. The Plan says the billed 
codes are not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes J1100, J2250, J2370, J2405, J2704, J3010, J7120, & D7140 are not supported in the 
medical record. Specifically, codes J1100, J2250, J2370, J2405, J2704, J3010, & J7120 have a status of "N" 
and are not separately payable. Code D7140 is considered a dental service and is non-covered. Based on this 
information, we decided that Medicare rules for coverage of procedure codes J1100, J2250, J2370, J2405, 
J2704, J3010, J7120, & D7140 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes J1100, J2250, J2370, J2405, J2704, J3010, J7120, & D7140 provided on February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network set of injections provided on 
February 23, 2023, and March 2, 2023. 
 
You asked the Plan to waive the copayment for an in-network set of injections. You say that you want this 
covered. This $800 bill is far too high, and no one told you ahead of time that the procedure was only covered 
at 80%.  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 20% 
coinsurance, and a maximum out of pocket (MOOP) amount of $800 for Medicare Part B prescription drugs.  
 
The allowed amount was $3,625.58 resulting in a $725.12 coinsurance ($3,625.58 x 20% = $725.12).  Your remaining out-of-pocket maximum is $74.88 for the 2023 Plan year ($725.12 + $74.88 = $800). 
You have been asked to pay an $800 cost for an in-network set of injections. This item/service falls within the 
Medicare Part B prescription drugs 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 
an in-network set of injections provided on February 23, 2023, and March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye appointment provided on January 23, 2023. 
 
You asked the Plan to pay for an eye appointment. You say that this was a routine office visit and should be 
covered. 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 an eye appointment 
provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and spine x-rays provided on 
November 17, 2022. 
 
You asked the Plan to pay for a new patient office visit, and spine x-rays. You say that these services were 
medically necessary. 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 a new patient office 
visit, and spine x-rays provided on November 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (74230, 74240, 72040, 70100, 70310) 
provided on December 30, 2022. 
 
You asked the Plan to pay for the radiology services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 74230, 74240, 72040, 70100, and 70310 is not supported in the medical record. 
Specifically, the claim was billed with place of service 11 (outpatient), however records show this service was 
performed in a mobile setting at a Skilled Nursing Facility. There is a more accurate place of service code for 
this setting. Based on this information, we decided that Medicare rules for coverage of the radiology services 
have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (74230, 
74240, 72040, 70100, 70310) provided on December 30, 2022.