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

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the requested device is not medically necessary.  
 
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 device. Our physician reviewer 
found a portable oxygen concentrator is medically unnecessary because Medicare criteria are not met. You 
have obesity, hemolytic anemia, and congestive heart failure, and are on supplemental oxygen. You are 
requesting the portable oxygen concentrator for travel, which is not covered by Medicare. In addition, there is 
no documentation that the oxygen saturation (SpO2) can be maintained above 91 percent during activity using 
an oxygen conserving device, with flow rate 1 to 4 liters a minute. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair. 
 
You asked the Plan to pre-approve ultra lightweight manual wheelchair. You say that you need a wheelchair, 
but the standard wheelchair is too heavy. The Plan denied your request. The Plan says you have not had a 
specialty evaluation for this wheelchair.  
The Plan follows Medicare rules. Medicare rules state that an ultra lightweight manual wheelchair is only 
covered if specified criteria have been met. 
 
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 ultra lightweight manual wheelchair. 
Our reviewer says that you do not meet criteria for this wheelchair. Our physician reviewer found there is 
insufficient clinical documentation regarding your upper and lower extremity strength and why you cannot 
propel a standard or lightweight manual wheelchair to necessity an ultra lightweight wheelchair. There is also 
insufficient documentation that your home is accessible for the requested wheelchair and that you can safely 
propel it. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultra lightweight manual wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultra lightweight manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram, routine ECG provided on November 22, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for electrocardiogram, routine ECG. You say that the services should be covered. 
The Plan denied your request. The Plan says this 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 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 electrocardiogram, routine ECG provided on 
November 22, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95913 and 95885 billed for date of service 
October 21, 2021.  
 
You asked the Plan to pay for procedure codes 95913 and 95885. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 95913 and 95885 is bundled into 
payment for code 95860. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
95913 and 95885 are column II codes to column I code 95860 with a modifier indicator of 0. The column II 
codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95913 and 95885 billed for date 
of service October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87636 for date of service February 3, 2023. 
 
You asked the Plan to pay for procedure code 87636. You say that you disagree with the Plan's denial. 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 procedure code 87636 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87636 for date 
of service February 3, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the IRF benefit within Medicare is precisely intended to ensure the fully and prompt recovery of 
Beneficiaries such as this one, who risk not being successful in lesser care settings. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 waive the copayment for the outpatient office visit (99204) provided 
on December 5, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that the provider never 
informed you that this would be a medical visit and not an eye exam. You also say that you could not refuse, as 
you were not given a chance to refuse treatment. 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 enrollees 
must pay a $35 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of 
the eyes under the vision care benefit category.  
You have been asked to pay a $35 copayment for the outpatient office visit. This item/service falls within the 
vision care benefit category. Specifically, the record shows that you received a medical eye exam for the 
diagnoses of Vitreous degeneration, left eye (H43.812) and Cortical age-related cataract, bilateral (H25.013). 
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 outpatient office visit (99204) provided on December 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the acupuncture services provided 
from January 10, 2023, to January 24, 2023. 
 
You asked the Plan to increase the reimbursement for the acupuncture services. You say that you should be 
reimbursed $50 per visit. The Plan denied your request. The Plan says you were reimbursed the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Medicare-covered acupuncture services.  
 
 
 
 You have been asked to pay a $35 copayment for each acupuncture service provided on January 12, 2023, 
January 17, 2023, and January 24, 2023. You have also been asked to pay a $35 copayment for each of the two 
acupuncture services provided on January 10, 2023. The record shows you should only be reimbursed $27.22 
per day, which is the maximum allowable amount for the acupuncture services provided on January 12, 2023, 
January 17, 2023, and January 24, 2023. The record also show you should only be reimbursed $54.44 for each 
of the two acupuncture services provided on January 10, 2023. These items/services fall within the acupuncture 
for chronic low back pain benefit category. This means that you have reimbursed 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 increase the reimbursement for the 
acupuncture services provided from January 10, 2023, to January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Spotify membership purchased on April 11, 2023. 
 
  You asked the Plan to pay for the Spotify membership. You say that you have tinnitus and purchased this 
membership to mask the tinnitus at night. You also say that you understand that Spotify is not a normally 
approved OTC item, but you would like to know what the difference is between using Spotify as a sleep aid 
and OTC sleep aids. The Plan denied your request. The Plan says Spotify is not a covered item and is not 
reimbursable. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. The rules also 
say that for equipment to be covered, it must primarily serve a medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Although your 
plan offers a supplemental benefit for OTC items, Spotify is not listed as a covered item. Therefore, we decided 
that the Plan does not have to pay for the Spotify membership purchased on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three arch supports plus overlay cushions for your shoes 
purchased on January 14, 2023. 
 
You asked the Plan to pay for the three arch supports plus overlay cushions. You say that you spent the money 
as you wished and would like the $350 to be reimbursed as the brochure states. The Plan denied your request. 
The Plan says these items are not covered benefits. 
 
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. Even though the Plan offers a supplemental benefit for specific items and services, arch supports and 
overlay cushions are not covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the three arch supports plus overlay cushions for your shoes purchased on January 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that  The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and your needs can be met in another setting.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87624 for date of service June 27, 2022. 
 You asked the Plan to pay for procedure code 87624. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Medicare does not cover this test solely for screening purposes. The test at issue in this appeal, procedure code 
87624, was requested solely for screening purposes. Code 87624 was billed with a screening diagnosis code 
(Z11.51). However, code 87624 is not a screening code; therefore, the code is not payable as billed. Therefore, 
we decided that the Plan does not have to pay for procedure code 87624 for date of service June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus vaccine (Td) (90714) and vaccine administration 
(90471) provided on January 20, 2023.  
You asked the Plan to pay for the vaccine services. You say that your Tetanus shot was over ten years old. You 
say that your doctor wanted you to give it to you during your annual physical. You also say that this should be 
covered. The Plan denied your request. The Plan says when a Part D Medicare-covered immunization is 
received in a provider's office or outpatient setting you will pay the cost of the immunization and 
administration to the provider. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the Tetanus vaccine (Td) (90714) and 
vaccine administration (90471) provided on January 20, 2023.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs interdisciplinary therapy care and 
daily physician oversight. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF 
services requested do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. While the medical records support a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frame, the scratch resistant coating, and the 
progressive lens provided on February 21, 2023. 
 
You asked the Plan to pay for the deluxe frame, the scratch resistant coating, and the progressive lens. You say 
that both claims should be eligible for payment. The Plan denied your request. The Plan says the benefit has 
been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses and pair of lenses or contact lenses per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, you received contact lenses on January 9, 2023, which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the deluxe 
frame, the scratch resistant coating, and the progressive lens have not been met. Therefore, we decided that the 
Plan does not have to pay for the deluxe frame, the scratch resistant coating, and the progressive lens provided 
on February 21, 2023.  
 
Your complaint about the benefit design is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollee's needs can be met at an alternate level of care.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 7, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that the service should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on November 7, 2022, by 
an out-of-network (OON) provider.