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

 
We decided that the Plan does not have to reimburse you for the sales tax for non-prescription drug services 
provided on February 9, 2022 
 
You asked the Plan to reimburse you for the sales tax. The Plan denied your request. The Plan says Medicare 
does not make any additional payment for sales taxes and does not make adjustments in fees to reflect local 
changes in tax rate. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make any additional payment 
for sales taxes and does not make adjustments in fees to reflect local changes in tax rates. 
 
We looked at the file and Medicare rules. Medicare says that Medicare does not make any additional payment 
for sales taxes and does not make adjustments in fees to reflect local changes in tax rates. Therefore, we 
decided that the Plan does not have to reimburse you for the sales tax for non-prescription drug services 
provided on February 9, 2022
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has tried and failed 
conservative treatments. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the magnetic resonance imaging shows facet degenerative joint disease, 
foraminal stenosis, and disc bulging. The cause of the enrollee's back pain is unclear. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve a routine transport trip for a total of 112 miles. 
 
You asked the Plan to approve these services. You say that you need transportation to have lab work done. The 
Plan denied your request. The Plan says the request exceeds the mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation for 24 one-way trips and each one-way trip must not exceed 100 
miles. 
 
We looked at your request, the records in the case file, and the rules. The file shows that you have requested a 
one-way trip for a total of 112 miles. This exceeds the 100 mile-per-trip limitation. Based on this information, 
we decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we 
decided that the Plan does not have to approve a routine transport trip for a total of 112 miles.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a face down chair purchased on January 25, 2023. 
 
You asked the Plan to pay for a face down chair. You say that without the utilization of this device, recovery 
may have been compromised to such an extent as to require costly repeat surgery. The Plan denied your 
request. The Plan says the face down position be achieved by pillows. 
 
The Plan must follow Medicare rules. The rules 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. Therefore, we 
decided that the Plan does not have to pay for a face down chair purchased on January 25, 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 1, 2023, 
to January 27, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were placed in a room with 
another individual who had Covid-19, which caused you to be placed in quarantine and prevented you from 
being released within the 21 days.  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 $150 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $900 for a SNF stay ($150 per day x 6 days = $900). 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 1, 2023, to January 27, 2023.  
 
Your complaint about being quarantined and unable to leave within the 21 days 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from August 31, 2022, 
to September 12, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were advised you would not be 
charged for the skilled nursing facility stay. 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 $25 copayment each day for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay $300 for a SNF stay ($25 per day x 12 days = $300). 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 
August 31, 2022, to September 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair (K0861) and accessories. You say that the 
requested group 3 power wheelchair and accessories are medically necessary. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for a group 3 power wheelchair. As criteria for the group 3 
power wheelchair are not met, the accessories are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 power wheelchair (K0861) 
and accessories. Our reviewer says that the enrollee does not meet criteria for a group 3 power wheelchair. Our 
physician reviewer found a Group 3 power wheelchair can be covered if the medical necessity for a PWC is 
met and if the disorder causing the mobility limitation is a neurological condition, myopathy, or congenital 
skeletal deformity. The beneficiary also must require a drive control interface, power tilt or a power recline 
seating system and if there has been a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a physical or occupational therapist.  
 
In this case, the member has difficulties with ambulation.  The documentation does not indicate that the 
member has any pressure injuries or requires intermittent catheterization of the bladder or have spasticity that 
would necessitate power tilt or recline.  Although the members condition may meet criteria for a PWC, the 
criteria for this specifically requested PWC with multiple power options including power tilt and recline are not 
met. As criteria for the group 3 PWC are not met, the accessories are not medically 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 a group 3 power wheelchair (K0861) and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and 
accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 19, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says that the requested Intracept procedure is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous BVN is 
covered if all of the criteria listed in the Medicare rules section are 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 an Intracept procedure. Our reviewer 
says that the procedure is not medically necessary. Our physician reviewer found that there is no MRI showing 
only modic changes without facet degenerative joint disease or foraminal stenosis. The cause of the enrollee's 
back pain is unclear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor supply allowance (A4239) provided on 
February 17, 2023. 
 
You asked the Plan to pay for the continuous glucose monitor supply allowance (A4239). You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Per the LCD guidelines, this code is payable when the CGM is covered up to 
one every 30 days. There was no evidence that the CGM is not covered by the Plan, nor that this was billed less 
than 30 days from prior deliveries of supplies. The Plan did not provide the paid claim as evidence that this 
item was paid for less than 30 days ago. Therefore, we decided that the Plan has to pay for the continuous 
glucose monitor supply allowance (A4239) provided on February 17, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services (34710, 34711, 34713) provided on April 22, 
2022. 
 
You asked the Plan to pay for the surgical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says that although the decision on the case was not timely, in reviewing the 
documentation the Plan would have overturned the Plan's decision at the plan level if the Plan had processed it 
within the required timeframe. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan tried to say the appeal was not timely; however, there is no evidence of 
that. The Plan were the ones that did not render the decision within the required timeframe. Furthermore, the 
Plan even states had they made a decision on time it would have been overturned. Therefore, we decided that 
the Plan has to pay for the surgical services (34710, 34711, 34713) provided on April 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an office visit for a right prosthetic eye 
repair/replacement provided on November 24, 2022. 
 
You asked the Plan to reimburse you for an office visit for a right prosthetic eye repair/replacement .You say 
that your prosthetic eye had fallen on the ground and got scratched and damaged on November 23, 2022, in 
Europe. You say that your damaged eye was painful to use, and you were lucky to find a doctor who was kind 
to schedule a next day appointment on November 24, 2022, in Europe and the doctor replaced your new 
prosthetic eye on November 24, 2022. The Plan denied your request. The Plan says outpatient foreign (Europe) 
right prosthetic eye repair/replacement is not covered by Medicare or the members health Plan. 
 
The Plan contract the Plan covers worldwide emergency and urgently needed services outside the United States 
under the following circumstances: emergency services, including emergency or urgently needed 
care. 
 
We looked at the file and the Plans rules. The file shows that the services were not emergency or urgently 
needed services. Therefore, we decided that the Plan does not have to reimburse you for an office visit for a 
right prosthetic eye repair/replacement provided on November 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visits provided from 
January 4, 2023, to February 2, 2023. 
 
You asked the Plan to waive the deductible for the specialist office visits. You say that you do not understand 
why you are being billed for this. 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. Your 
contract with the Plan says that there is a $226 deductible which applies to physician/practitioner services. 
Your contract with the Plan also says that you must pay a $20 copayment after meeting the deductible for 
primary care provider office visits. 
 The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $226 deductible which applies to physician/practitioner services. This cost sharing is a contractual 
obligation that had not been met at the time the specialist office visits was received on January 4, 2023, to 
February 2, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the specialist 
office visits provided from January 4, 2023, to February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is experimental.  
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no documented magnetic resonance imaging that shows only Modic 
changes without facet joint syndrome or foraminal stenosis. The cause of back pain is not clear. 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve four home health physical therapy visits (G0151). 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four home health physical therapy visits (G0151).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the echocardiography (93306) provided on November 
23, 2022, by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the claim should be paid. The 
Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a 
network provider, and the services were not urgent or emergent, nor were they approved in advance. 
 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 
the echocardiography (93306) provided on November 23, 2022, by an out-of-network provider.