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

 
We decided that the Plan does not have to waive the copayment for out-of-network chiropractic services 
provided on June 12, 2023. 
 
You asked the Plan to waive the copayment for out-of-network chiropractic services. You say that you disagree 
with the copayment. 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 $50 
copayment for out-of-network chiropractic services. 
 
You have been asked to pay a $50 copayment for out-of-network chiropractic services. This item/service falls 
within the out-of-network chiropractic 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. However, since the allowed amount is less than the standard 
copayment, you only owe $39.79. Therefore, we decided that the Plan does not have to waive the copayment 
for out-of-network chiropractic services provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 18, 2023. 
 
You asked the Plan to pay for an office visit. 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 office visit provided 
on April 18, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services (76857) provided on May 4, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that code 76857 is a 
column II code to column I code 76815. 
 
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 argues that code 76857 is a column II code to column I code 76815. 
While this is true, the Plan has not provided documentation showing that code 76815 was billed for the date of 
service in question. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the services (76857) provided on May 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99496 billed for date of service March 27, 
2023. 
 You asked the Plan to pay for procedure code 99496. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99496 is bundled into payment for code 20610. 
 
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 code 99496 
is a column II code to column I code 20610. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 99496 billed for date of service March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that due to the instability of your severe stage 5 
COPD, this machine helps you maintain a quality of life and helps steady your breathing. The Plan denied your 
request. The Plan says you do not meet criteria for approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you were treated and responded to 
BiPAP therapy in the hospital, therefore, BiPAP therapy is appropriate intervention for your chronic respiratory 
failure. Whether or not average volume-assured pressure support (AVAPS) is added is to be determined to 
initial response but does not meet criteria for failed BiPAP. Hence, no home ventilation indicated per 
documentation. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with a single power option 
and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with a single power option. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the notes do not show that 
the enrollee has a qualifying condition which requires a Group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to a neurological condition, myopathy, or a congenital 
skeletal deformity. 
 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 with a 
single power option. Our reviewer says that the request for a Group 3 power wheelchair with a single power 
option is not medically necessary. Our physician reviewer found the provided documentation indicates that the 
enrollee has musculoskeletal disease. The documentation does not support that the enrollee has a condition that 
would qualify them for a Group 3 power wheelchair. Therefore, the reviewer found that the request for a Group 
3 power wheelchair with single power option is not medically reasonable or necessary in this case. 
 
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 with a single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with a single 
power option and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field test provided on April 17, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the visual field test. You say that you regularly comply with administrative 
requirements for payments. The Plan denied your request. The Plan says that authorization was not obtained for 
the service to be provided outside the Plan's 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 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 a visual field test provided on April 17, 2023, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 22, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration for 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 the laboratory services 
provided on February 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 14, 
2022, through June 15, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the service performed is not listed as an inpatient-only procedure per Centers for 
Medicare and Medicaid Services (CMS) Addendum E. The enrollee had no documentation of any complication 
or medical instability following surgery to support the expectation that the enrollee would require an inpatient 
hospital stay extending beyond two midnights. The review has determined that the record did not show that at 
the time of the inpatient admission it was reasonable for the admitting physician to expect that the enrollees 
necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two 
midnights with supporting documentation of the enrollees history and comorbidities, signs and symptoms, 
current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from June 14, 2022, through June 15, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria 50mg/4ml vial. 
 You asked the Plan to pre-approve Simponi Aria. You say that the medical records provided will show proof of 
medical necessity.  The Plan denied your request. The Plan says the criteria has not been met as there is no 
documentation that the enrollee has tried two of the preferred medications for RA. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Simponi Aria. Our reviewer says that 
the records do not show that criteria been met. Our physician reviewer found the Plan requires a trial of two of 
preferred medications of either Enbrel, Humira, Renflexis, Skyrizi, Cosentyx, or Rinvoq before they will 
approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no 
documentation provided indicating that the Plans required drugs) would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria 50mg/4ml vial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3.  
You asked the Plan to pre-approve a Freestyle Libre 3. You say that the enrollee would benefit from this 
continuous glucose monitor (CGM). The Plan denied your request. The Plan says the medical criteria for a 
CGM have not been 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. The documentation indicates that the enrollee does not have a history 
of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 3 have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that you 
would like a formal review and split decision rendered as deemed appropriate. The Plan denied your request. 
The Plan says the enrollee does not have a medical need for multiple power options included with the requested 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the request for a Group 3 power wheelchair with multiple 
power options is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has a high risk for skin breakdown, use a catheter intermittently, have spasticity or 
require an alternative means of managing power drive. Therefore, the reviewer found that the request for a 
Group 3 power wheelchair with multiple power options is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that despite aggressive treatment and the 
enrollee being compliant to BiPAP therapy, the enrollee continues to have life threatening exacerbations. The 
Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient because 
their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that there is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. Also, the enrollee has not tried and may 
benefit from BiPAP with AVAPS during sleep as an outpatient. Therefore, a home ventilator is 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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair, cushion, pill organizer and sales tax. 
 
You asked the Plan to pay for the wheelchair, cushion, pill organizer and sales tax. You say that the items 
should be covered. The Plan denied your request. The Plan says this cost sharing for the wheelchair and 
cushion was charged correctly. The pill organizer does not primarily serve a medical purpose and sales tax is 
not covered. 
 
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 $500 deductible which applies to durable medical equipment (DME). 
The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare does not 
make separate payment for sales tax.   
 
The item or service you asked the Plan to pay for falls within the durable medical equipment (DME) benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to durable medical equipment (DME). This cost sharing is a contractual obligation 
that had not been met at the time the wheelchair and cushion was received on April 22, 2023. A pill organizer 
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 the wheelchair, cushion, pill organizer and sales tax.
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 you remain in the SNF even though you were 
discharged on October 2, 2023. You also say that you are not physically ready to go home as there is no one 
there to help you walk to/from the bathroom and you need more physical therapy to get more strength to walk 
on your own. The Plan denied your request. The Plan says your condition no longer requires skilled services on 
a daily basis.  
 
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 You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Based on 
the medical records provided there is no documentation that further daily skilled services are required. You are 
walking household distances with a rolling walker with supervision level to independence and is supervision 
level to independent for transfers and for activities of daily living. Provided records do not document a 
significant decline in your functional status compared to your recent baseline to necessitate further daily 
inpatient skilled therapy services. There is no documentation that you require the services on an inpatient basis, 
only in a skilled nursing facility setting. Records support that services in the home with home health care or in 
a long-term care facility on a part time basis are appropriate in this case 
 
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.