Persius/hicric huggingface dataset:
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 you are requesting reconsideration of the 
denial and have provided medical records. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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. 
 
 
 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 the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the 
enrollee was successfully treated with a bilevel positive airway pressure (BiPAP) device. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure 
support (AVAPS) capability and failure of such a device has not been documented. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on March 13, 2023. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you say that the enrollee received 
services in a nursing home setting and could not choose an in-network provider since they have an exclusive 
contract with the facility. 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 skilled nursing facility 
care provided on March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a tendon repair procedure provided on 
March 06, 2023. 
 
You asked the Plan to reduce the copayment for a tendon repair procedure. You say that you were told that you 
would only be charged $270 for the procedure. 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 $370 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $370 copayment for a tendon repair procedure. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the copayment for a tendon repair procedure provided on March 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were billed correctly and were 
medically necessary. The Plan denied your request. The Plan says no separate payment is made for these lab 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that payments for lab services for beneficiaries in a 
Part A stay in a skilled nursing facility (SNF), are included in the SNF Prospective Payment System (PPS) rate.  
No separate payment is made.  
 
In this case, the patient was in a covered SNF stay at the time of the lab services.  As a result, these lab services 
are part of the SNF PPS payment and no separate payment can be made. 
 
 
 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. Therefore, we decided that the Plan does not have to pay for lab 
services provided on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the service is not separately payable. 
 
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, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 was billed to identify 
Train of Four testing. Train of Four Testing does not fit the criteria set by CMS and Insurance Carriers for CPT 
95937. There is no separate code for Train of Four Monitoring, therefore, it would be inappropriate to bill the 
Neuromuscular Junction Testing code for Train of Four Monitoring. 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 procedure code 95937 billed for date of service October 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retroperitoneal ultrasound provided on February 23, 2022. 
 
You asked the Plan to pay for a retroperitoneal ultrasound. You say that authorization is not required for out-of-
network providers. 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 a retroperitoneal 
ultrasound provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 81479 billed for date of service July 18, 2022. 
 
You asked the Plan to pay for code 81479. You say that Medicare pays for this testing. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of code 81479 have not 
been met. Therefore, we decided that the Plan does not have to pay for code 81479 billed for date of service 
July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connector (E2310). 
 
You asked the Plan to pre-approve an electronic connector. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says this item 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 electronic connector. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate upper body strength to manage the standard power 
drive controls. 
 
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 electronic connector have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connector (E2310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on April 10, 2023. 
 
You asked the Plan to waive the copayment for office visit. You say that you say that the service should be 
covered. 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 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 May 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
January 17, 2023. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you do not think you 
should owe anything. 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 $325 
copayment for in-network surgical services performed at an outpatient hospital facility. 
 
You have been asked to pay a $325 copayment for a diagnostic colonoscopy. This item/service falls within the 
in-network surgical services performed at an outpatient hospital facility 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 diagnostic colonoscopy provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on January 30, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. 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 home visit for 
evaluation provided on January 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance ride provided on September 16, 2022. 
 
You asked the Plan to pay for an ambulance ride. You say that you want to make sure your insurance covers 
this. It was medically necessary. 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 ambulance ride 
provided on September 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiovascular stress test provided on 
May 02, 2023. 
 
You asked the Plan to waive the copayment for a cardiovascular stress test. You say that you do not agree with 
the copayment applied to this service. 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 in-network Medicare-covered diagnostic procedures and tests. 
 
You have been asked to pay a $40 copayment for a cardiovascular stress test. This item/service falls within the 
in-network Medicare-covered diagnostic procedures and tests 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 cardiovascular stress test provided on May 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network pneumatic compression 
device provided from January 14, 2023, to February 14, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network pneumatic compression device. You say 
that this was medically necessary and should be fully covered. 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% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
The 20% coinsurance for both months has resulted in a $940 total coinsurance ($323.81 + $616.19 = $940). You have been asked to pay a $940 total coinsurance for an out-of-network pneumatic compression device. 
This item/service falls within the durable medical equipment (DME) and related supplies 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 coinsurance for an out-of-network pneumatic compression device provided 
from January 14, 2023, to February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0856, E0955, 
E1002, E1028, E2310, E2361, E2607). 
 
 
 
 You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee is a 
heightened risk for developing pressure injuries from prolonged sitting and being unable to redistribute weight. 
The wheelchair and accessories with the power option is medically necessary. The Plan denied your request. 
The Plan says this special power wheelchair is medically necessary when an enrollee has need for power tilt or 
power recline. The enrollee does not meet criteria for the requested wheelchair and accessories. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a diagnosis of Parkinson's disease. Provided records do 
not support that the enrollee is high risk for skin breakdown (he uses a "walker/cane for short distances"), has a 
history of pressure ulcer(s) or has had skin flap surgery. Records do not document the enrollee performs 
bladder self-catheterization and is unable to transfer independently or that the enrollee has increased muscle 
tone or spasticity to meet criteria for the single power option wheelchair base, power tilt. As the wheelchair 
base does not meet Medicare criteria for coverage, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0856, E0955, E1002, E1028, 
E2310, E2361, E2607).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine, provided on February 24, 2023. 
 
You asked the Plan to pay for the shingles vaccine. You say that you were told the shingles vaccine was free. 
The Plan denied your request. The Plan says Medicare does cover the shingles vaccination but only under the 
Medicare Part D benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine, provided on 
February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing exam on March 16, 2023. 
 
You asked the Plan to waive the copayment for hearing exam. You say that you were told that a hearing exam 
is covered once a year. 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 $35 
copayment each Medicare-covered exam to diagnose and treat hearing and balance issues. Diagnostic hearing 
and balance evaluations performed by your provider to determine if you need medical treatment are covered as 
outpatient care when furnished by a physician, audiologist, or other qualified provider. The provider billed in 
the amount of $71 and the allowed amount is $31.85. This is less than the copayment amount. Therefore, 
results in the total cost sharing amount of $31.85. You have been asked to pay a $31.85 copayment, which is less than the copayment for hearing exam. This 
item/service falls within the hearing services (Medicare-covered) 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 hearing exam on March 16, 2023.