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

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 27, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were 
transported to an in-network provider. 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 $290 
copayment for ambulance services. 
 
You have been asked to pay a $290 copayment for the ambulance transportation. This item/service falls 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 transportation provided on December 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the parking fees (S9975) provided from 
November 18, 2020, to December 30, 2020. 
 
You asked the Plan to reimburse you for the parking fees. You say that you would like to be reimbursed for the 
hospital parking fees. The Plan denied your request. The Plan says parking fees are not covered by Medicare, 
and no payment can be issued. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Specifically, parking fees would not fall under the definition of 
reasonable transportation to a distant facility. In addition, the Plans contract language specifies that their 
coverage of transplant service related transportation costs is limited to costs to and from the facilities providing 
transplant related care. Parking fees are not considered reasonable and necessary for the diagnosis or treatment 
of an illness or injury. Based on this information, we decided that Medicare rules for coverage of the parking 
fees have not been met. Therefore, we decided that the Plan does not have to reimburse you for the parking fees 
(S9975) provided from November 18, 2020, to December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) and a bone 
replacement graft (D7953) provided on December 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that your coverage says implants are covered with a 
50% coinsurance. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the bone replacement graft and any service related to implants are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical placement of implant body (D6010) and a bone replacement graft (D7953) provided on December 30, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotic insoles provided on August 30, 2022. 
 
You asked the Plan to pay for the foot orthotic insoles. You say that this claim is for foot orthotic insoles and it 
is medically necessary due to neuropathy and tendonitis in your feet. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotic insoles provided on 
August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthroplasty, left wrist-interposition, intercarpal or 
carpometacarpal joints (25447) . 
 
You asked the Plan to pre-approve the arthroplasty, left wrist-interposition, intercarpal or carpometacarpal 
joints. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 
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 the arthroplasty, left wrist-interposition, 
intercarpal or carpometacarpal joints. Our reviewer says that the requested service is not considered medically 
reasonable and necessary in this case. Our physician reviewer found there are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 arthroplasty, left wrist-interposition, intercarpal or carpometacarpal joints 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the arthroplasty, left 
wrist-interposition, intercarpal or carpometacarpal joints (25447) .
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 10, 2022, to 
April 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 10, 2022, to April 
4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for an 
IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 16, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. 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 the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for breast prostheses (L8000), a mastectomy bra (L8030), 
and does not have to reimburse you for sales tax purchased on December 12, 2022.  
You asked the Plan to pay more for breast prostheses, a mastectomy bra, and to reimburse you for sales tax. 
You say that these items should be covered. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. Sales tax is not separately paid. 
 
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.  
 
You have been asked to pay a 20% coinsurance for breast prostheses, and a mastectomy bra. These items fall 
within the durable medical equipment benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The Plan only covers up to the Medicare allowable less the cost sharing. Sales 
tax cannot be separately paid. Therefore, we decided that the Plan does not have to pay more for breast 
prostheses (L8000), a mastectomy bra (L8030), and does not have to reimburse you for sales tax purchased on 
December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite test strips. 
 
You asked the Plan to pre-approve the FreeStyle Lite test strips. You say that the Onetouch needle is hard to 
use and you find it easier to use the Freestyle test strips. The Plan denied your request. The plan says that the 
provider has not provided supporting documentation that indicates a medically necessity for Freestyle Lite test 
strips why preferred products are not clinically appropriate. The Plan says only the preferred brand products 
listed in the EOC are covered.  
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the FreeStyle Lite test strips. Therefore, we decided that the Plan does not have to pre-approve FreeStyle 
Lite test strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are necessary for the 
enrollee to return to their baseline function. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the resin-based composites (D2330) for tooth #8, #9, 
and #11. 
 
You asked the Plan to pre-approve the dental services. You say that your dentist says the restorations will 
reduce the sensitivity in your teeth. The Plan denied your request. The Plan says your benefit for the requested 
items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan approved the resin-based composites (D2391 and D2330) for tooth #5 and #6 on December 15, 
2022; therefore, your benefit for the requested items or services was exhausted on the date of approval of 
December 15, 2022. Therefore, we decided that the Plan does not have to pre-approve the resin-based 
composites (D2330) for tooth #8, #9, and #11.
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 October 22, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had to 
call the paramedics because you cannot get into a vehicle to go to the hospital. You also ask to review all 
submitted records which show this service was a medical necessity. 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 October 22, 2022. 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 October 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroscopy procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request 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 the requested services. Our physician 
reviewer found that the enrollee is being treated for left knee medial meniscus tear with displaced flap. The 
noted magnetic resonance imaging (MRI) demonstrated pathology of the left knee that correlates with her 
subjective complaints and objective findings. The MRI is considered diagnostic. The rationale for the need for 
additional diagnostic studies/procedures is not evident. Moreover, detailed documentation regarding a trial and 
failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident.  No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of 
this request as an exception. Therefore, the requested left knee arthroscopy, in this case, 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a knee arthroscopy procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH can render services that will 
improve the enrollee's condition and avoid unnecessary hospital readmission. The Plan denied your request. 
The Plan says the enrollee does not meet all the requirements for admission to an LTACH. 
 
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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220) and prophylaxis - adult (D1110) provided on January 10, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that the booklet you were given indicates basic 
dental would be covered. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for periodic oral evaluation - established patient 
(D0120), intraoral - periapical first radiographic image (D0220) and prophylaxis - adult (D1110) provided on 
January 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq tablets 
 
You asked the Plan to pre-approve Myrbetriq tablets. The Plan denied your request. The Plan says Myrbetriq is 
a self-administered drug, and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Myrbetriq tablets   
Benefits for Myrbetriq tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.