Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy (PT) evaluation 
provided on January 10, 2023. 
 
You asked the Plan to waive the copayment for a physical therapy (PT) evaluation. You say that no physical 
therapy services were performed. 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 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for a physical therapy (PT) evaluation. This item/service falls 
within the outpatient rehabilitation 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 a physical therapy (PT) evaluation provided on January 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 19, 
2023, to March 1, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were exposed to Covid-19 and 
did not receive the care you needed, so you should not be required to pay the cost share. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $4,312 for a SNF stay ($196 per day x 22 days = $4,312). This item/service falls 
within the SNF 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 a SNF stay provided 
from January 19, 2023, to March 1, 2023.  
 
Your complaint about being exposed to Covid-19 and not receiving the necessary care 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on March 27, 2023, to April 24, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that the facility did 
not collect copayment at the time of service and you were advised the services were covered 100%. 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total you owe is $320 for outpatient rehabilitation services ($40 per 
visit x 8 visits = $320). Therefore, we decided that the Plan does not have to waive the copayment for each 
physical therapy (PT) visit provided on March 27, 2023, to April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings (A6530) provided on April 17, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the compression stockings. You say that you need this product for wound care 
regularly and want to be reimbursed for your out-of-pocket expenses. The Plan denied your request. The Plan 
says the out-of-network 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 at issue in this appeal. The Plan did not pre-approve the items at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for compression stockings (A6530) provided on April 17, 2023, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ophthalmologist office visit to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve an ophthalmologist office visit. You say that you feel as if a past doctor 
made you blind, so you want to see the requested doctor. The Plan denied your request. The Plan says the 
documentation indicates that your needs can be met in-network. The Plan also says that there are 25 in-network 
providers within a 20-mile radius of the member's address. 
 
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 
an ophthalmologist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lower spinal canal. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary you and you 
will be starting physical therapy soon. The Plan denied your request. The Plan says that your records do not 
show symptoms supporting the requested imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found you have low back pain and increasing right leg 
pain.  You are post-polio syndrome and do not ambulate well. Your exam was compromised by the post-polio 
syndrome and your inability to ambulate well. Based upon these factors the requested MRI lumbar spine should 
be approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the lower spinal canal.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve binaural hearing aids (V5221). 
 
You asked the Plan to pre-approve binaural hearing aids (V5221). You say that you have arthritis, which makes 
it hard to put previous aids on. The Plan denied your request. The Plan says these services are not a Plan 
covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the member is pregnant or resides in a nursing facility.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of binaural hearing aids (V5221) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve binaural hearing aids (V5221).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #26 and a retainer crown 
(D6740) for tooth #27. 
 
You asked the Plan to pre-approve the dental services. You say that you need the dental work completed 
because you bite your tongue. The Plan denied your request. The Plan says your benefit for the requested items 
or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved a pontic (D6245) for tooth #24 and #25 and a retainer crown (D6740) for tooth 
#22 and #23 on July 10, 2023; therefore, your benefit for the requested items or services was exhausted on the 
date of approval of July 10, 2023. Therefore, we decided that the Plan does not have to pre-approve a pontic 
(D6245) for tooth #26 and a retainer crown (D6740) for tooth #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you are unstable on your feet due to all your 
co-morbidities and need the shower to bathe on your own. The Plan denied your request. The Plan says this 
item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision including lipectomy. 
 
You asked the Plan to pre-approve an excision including lipectomy. You say that you need this surgery. The 
Plan denied your request. The Plan says this procedure is considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked the file and Medicare rules. Based on this information, we decided that an excision including lipectomy is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve an 
excision including lipectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) for teeth #2, 3, 4, 5, 12, 
13, 14, and 15. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
endosteal implant (D6010) for teeth #2, 3, 4, 5, 12, 13, 14, and 15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service July 18, 
2022, to August 16, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the HIPPS code 
is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim was submitted with HIPPS code 1AA11. We find that the HIPPS code is not supported in the 
medical record. The records do not show that this period of care is considered an early admission. The records 
also do not show that the enrollees condition falls under the clinical group of medical management, teaching 
and assessment (MMTA)  other. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health care billed for dates of service July 18, 2022, to August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve accu-chek diabetic test strips. 
 
You asked the Plan to pre-approve the accu-chek diabetic test strips. You say that the items should be covered 
as the enrollee disagrees with the denial. The Plan denied your request. The Plan says only the preferred brand 
products listed in the EOC are covered.  
 
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the diabetic test strips, the record does not support the medical necessity for accu-chek test strips to be 
approved over the Plans preferred brands. Therefore, we decided that the Plan does not have to pre-approve 
accu-chek diabetic test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for free thyroxine assay test provided on January 12, 2023. 
 
You asked the Plan to pay for free thyroxine assay. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the records submitted do not include a signed physician order for 
this specific test. 
 The Plan must follow Medicare rules. Medicare rules say that lab tests must be specifically ordered by the 
physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The record does not include a physician order for this specific lab 
test. Based on this information, we decided that Medicare rules for coverage of free thyroxine assay have not 
been met. Therefore, we decided that the Plan does not have to pay for free thyroxine assay test provided on 
January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 16, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) 
supplies (A4556, A4557, and A4630). 
 
You asked the Plan to pay for the TENS supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the items should be covered. 
 
The Plan follows Medicare rules. Medicare rules say that TENS therapy for Chronic Low Back Pain (CLBP) 
will be denied as not reasonable and necessary. 
 
A TENS device is not covered for chronic low back pain. Since the TENS device is not covered, the supplies 
will also be denied. Based on this information, we decided that Medicare rules for coverage of a supplies for a 
TENS device have not been met. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulator (TENS) supplies (A4556, A4557, and A4630).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the request for more information from the enrollee's 
physician indicates that the enrollee does have diabetes, use insulin, had an in-person visit with their treating 
physician to evaluate their diabetes control and to determine whether the criteria for coverage have been met. 
Based on this information, we decided that Medicare rules for coverage of the CGM have been met. Therefore, 
we decided that the Plan has to pre-approve a continuous glucose monitor (CGM).  
  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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot walk, have difficulty feeding yourself, 
and tire easily. The Plan denied your request. The Plan says your condition does not meet Medicare guidelines 
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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.