Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 7, 
2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multivitamin IV fluids. 
 
You asked the Plan to pre-approve multivitamin IV fluids. You say that it is medically necessary. The Plan 
denied your request. The Plan says it does not meet the criteria.  
 
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 multivitamin IV fluids. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that IV multivitamins are 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 multivitamin IV fluids have not been met. Therefore, we decided that the Plan 
does not have to pre-approve multivitamin IV fluids.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says these services may be completed in a lower level 
of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting currently being offered. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that for more than 3 months you have 
been requesting pre-authorization of compression means so that your blood flows. You also say that you do not 
have ulcers or even sores, but annoying black feet which is why you urgently need the authorization before 
your legs are cut off. The Plan denied your request. The Plan says you are not suffering from active ulcers, or 
any burn and/or recent surgical wound that need compression garment to secure dressings. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 very heavy-duty power wheelchair with single 
power option (K0860) and additional items and accessories (codes E2363, E1028, E1002, E0955, E2310, 
E2608, and E1028). 
 
You asked the Plan to pre-approve a group 3 very heavy-duty power wheelchair and additional items and 
accessories. You say that the provided documentation supports the need of the custom medical equipment 
being requested for the enrollee. The Plan denied your request. The Plan says the enrollee does not have 
medical need for power tilt option included with K0860 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with single 
power option (such as code K0860) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 very heavy-duty power 
wheelchair and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria 
for coverage. Our physician reviewer found the enrollee has obesity and uses a power wheelchair. The 
enrollee's current power chair is not functioning, and they have been using a manual wheelchair. Our reviewer 
found that the enrollee has intact skin and is able to walk limited distances with an assistive device. Our 
physician reviewer also found that the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive.  
 
 
 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 very heavy duty power wheelchair and additional items and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 very 
heavy-duty power wheelchair with single power option (K0860) and additional items and accessories (codes 
E2363, E1028, E1002, E0955, E2310, E2608, and E1028).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing frame system. 
 
You asked the Plan to pre-approve the requested item. You say that the enrollee has a history of pressure ulcers 
from prolonged sitting. The Plan denied your request. The Plan says the item is not covered for any condition. 
 
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. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a standing frame system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires continued medical and pain 
management along with physical and occupational therapies The Plan denied your request. The Plan says the 
enrollee's condition does not meet all of the requirements for inpatient rehabilitation admission. The Plan says 
services may be provided at a lower 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
20, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were informed that 
you would be transported to the emergency room (ER) and you were not allowed to speak to your husband who 
was waiting for you in the urgent care facility. You also say that the ER was across the street and your husband 
could have driven you. 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 enrollees must pay a 
$200 copayment per one-way ambulance trip. 
 You have been asked to pay a $200 copayment, for the ambulance services. The ambulance services fall  
within the ambulance 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 the 
ambulance services provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network (OON) 
provider on June 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were in a lot of pain, and no one would see 
you. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network (OON) provider on June 5, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on May 25, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on May 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 18, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that a call was 
made for service due to the extreme pain from you passing a kidney stone. You also say that you had no choice 
in the matter of what service you would receive and feel the pan should negotiate this claim of $200. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 18, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 12, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
enrollee fell and needed help getting up. The assisted living facility called the ambulance and you feel they 
should be billed for the service. The Plan denied your request. The Plan says these services are not a covered 
benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 12, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on March 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve inpatient rehabilitation facility (IRF). You say that the facility is close to 
your home and close to your family. The Plan denied your request. The Plan says there are several in-network 
(INN) facilities that can provide the required service. 
 
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 
inpatient rehabilitation facility (IRF) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428). 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the patient's 
condition has deteriorated and now requires hospice services. You also say that the patient will require 
ambulance transport to transfer them to home hospice services. The Plan denied your request. The Plan says the 
medical records received do not support this service because there is no medical need for the patient to require 
an ambulance. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation. Our reviewer says that ambulance transport is not reasonable nor medically necessary. Our 
physician reviewer found the records do not show the patient is unable to sit in a reclined position and is bed-
bound. The patient does not have any acute conditions which require continuous monitoring. Our reviewer also 
found that other modes of transportation are not contraindicated for this patient. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayments for two MRI scans. We decided that the Plan does not 
have to waive the copayment for one MRI scan. 
 
You asked the Plan to waive the copayments for three MRI scans provided on July 9, 2023. You say that you 
disagree with the cost share applied and feel you are being balanced billed. The Plan says that this cost sharing 
was charged correctly. We decided that the Plan has to waive the copayments for two MRI scans.  
 
The rules say a health 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 does not state in clear terms 
that you are required to pay a separate copayment for outpatient diagnostic radiology services performed on the 
same date of service by the same provider. Therefore, we decided that the Plan has to waive the $369.52 
copayment for two MRI scans.  
 
We also decided that the Plan does not have to waive the copayment for one MRI scan. 
 
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 $200 
copayment for outpatient diagnostic radiology services, including an MRI scan. Therefore, we decided that the 
Plan does not have to waive the $200 copayment for an MRI scan. 
 
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 pay for core buildup (D2950) and a crown (D2740) provided on July 
11, 2023, and July 25, 2023. 
  
You asked the Plan to pay for core buildup and a crown. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 core 
buildup (D2950) and a crown (D2740) provided on July 11, 2023, and July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85007 billed for date of service April 4, 
2023.  
 
You asked the Plan to pay for procedure code 85007. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 85007 is bundled into payment for code 85025.  

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 85007 
is a column two code to column one code 85025 with a modifier indicator of 0. The column two code is 
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 code 85007 billed for date of service April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2377, E2311, E2313). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you need this to be 
covered by the Plan. The Plan denied your request. The Plan says the notes do not show a medical need to 
control the power options through the joystick. 
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found your left upper extremity function and ability to eat independently 
support that you can control any power options with their own switches. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve upgraded electronics (E2377, E2311, E2313).