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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility services for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says daily skilled services are not required. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
or skilled therapy needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility services for the enrollee.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 patient may benefit from multiple therapies such as physical and occupational 
therapy but the documentation does not support that the patient's functional status requires an 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 acute inpatient rehabilitation facility (IRF) admission and services.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 you are medically stable with multiple past medical conditions with Cardiac Debility 
now with no evidence of complex medical issues that require monitoring by an inpatient physical, medicine, 
and rehabilitation (PMR) physician three times per week or need for acute rehab nursing care. While you may 
benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence of need for 
an intensive therapy program with decreased activity tolerance for therapy 3 hours per day with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. Admission to IRF is not medically 
necessary based on lack of medical complexity and current functional status with decreased activity tolerance. 
Your rehab needs can be met at an alternate, low intensity level setting such as an SNF or in-home with 
services. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion therapy services provided on December 12, 
2019 to February 13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the enrollee is being treated for severe pain. The 
Plan denied your request. The Plan says the billed codes are not payable by Original Medicare. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. In addition, the infusion services are not payable as billed. Medicare uses another code for reporting of, 
and payment for, these services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for the infusion therapy services provided on 
December 12, 2019 to February 13, 2020 by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-cataract eyewear provided on January 27, 2020. 
 
You asked the Plan to pay for the post-cataract eyewear. You say that that your 2020 plan documents clearly 
state that you are entitled to a pair of eyeglasses with a zero-dollar copay after covered cataract surgery. The 
Plan denied your request. The Plan says you must receive care from in-network providers with the exception of 
emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be 
provided with an in-network provider, which requires prior authorization from the plan.  
 
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 did not pre-approve the 
post-cataract eyewear. We found no exception that would require the Plan to pay for this service. Therefore, we 
decided that the Plan does not have to pay for post-cataract eyewear provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nucleic acid assays (87631) provided April 12, 2020.  
 
You asked the Plan to pay for nucleic acid assays. You say that you have attached the medical records and the 
documentation that supports no medical policies existing. Please review and reprocess for payment. The Plan 
denied your request. The Plan says this service is non-covered by Medicare and is excluded from coverage. 
 
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 pay for nucleic acid assays. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the documentation the enrollee was evaluated in the ED for syncope. There is no 
evidence of respiratory signs or symptoms.  A chest x-ray was without acute disease. The ordering of the 
respiratory panel was for screening purposes and was not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nucleic acid assays have not been met. Therefore, we decided that the Plan does 
not have to pay for nucleic acid assays (87631) provided April 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computerized tomography (CT) scan 
you had on May 19, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you cannot afford to pay this 
amount. The Plan denied your request. The Plan says you were charged this copayment 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 $100 
copayment for advanced imaging services provided in a doctor's office.  
 
You have been asked to pay a $100 copayment for the CT scan. The CT scan falls within the advanced imaging 
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 computerized 
tomography (CT) scan you had on May 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation services you received at an 
outpatient hospital facility on March 12, 2020. 
 
You asked the Plan to waive the coinsurance for the radiation services. You say that these services should be 
covered in full by your insurance. The Plan denied your request. The Plan says you were charged this 
coinsurance 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 20% 
coinsurance for radiation therapy.  
 
You have been asked to pay 20% coinsurance for the radiation services. 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 radiation services you received at an outpatient hospital facility on March 12, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99285) on March 
10, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you have very low 
income and cannot pay this amount. The Plan denied your request. The Plan says the correct copayment was 
applied. 
 
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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for an emergency room visit. An emergency room visit falls 
within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit (99285) on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on February 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that it is the facility's responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the facility 
or the provider. The Plan says that since prior authorization was not obtained, payment has been correctly 
denied. 
 
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 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 physician services provided on February 4, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography procedure (93306) 
performed on January 25, 2020. 
 
You asked the Plan to waive the copayment for an echocardiography procedure. You say that due to your age 
this service should only have a $30 copayment. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
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 $160 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
You have been asked to pay a $160 copayment for an echocardiography procedure. An echocardiography 
procedure falls within the "Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for an echocardiography procedure (93306) 
performed on January 25, 2020.  
 
Your complaint about receiving erroneous or misleading copayment information from the provider is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intravitreal injection provided on April 
15, 2020. 
 
You asked the Plan to waive the copayment for an intravitreal injection. You say that you have never been 
charged in the past and cannot afford the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $100 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received an intravitreal injection on April 15, 2020, at an outpatient hospital facility. An intravitreal 
injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $100 
copayment.   
 
You have been asked to pay a $100 copayment for an intravitreal injection. An intravitreal injection falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 an intravitreal injection provided 
on April 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Aflibercept injections (J0178) received on 
April 27 and June 1, 2020. 
 
You asked the Plan to waive the coinsurance for Aflibercept injections. You say that this charge is causing 
serious financial issues for you. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must 
pay 20% coinsurance for Part B drugs obtained in a provider's office.  
 
The enrollee has been asked to pay $548.90, or 20% coinsurance of the Plan-allowed amount of $2,744.50 for 
April 27, 2020, plus $375.38, or 20% coinsurance of the Plan-allowed amount of $1,876.89 for June 1, 2020, 
for Aflibercept injections. Aflibercept injections fall within the "Medicare Part B prescription drugs" benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for Aflibercept injections (J0178) 
received on April 27 and June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total electric hospital bed provided on March 7, 2019. 
 
You asked the Plan to pay for the hospital bed. The Plan denied your request. The Plan says the hospital bed is 
not covered by Medicare or the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital 
bed provided on March 7, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 7, 2019. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on June 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on June 10, 2020. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says you must use a 
network participating provider. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
We looked at the file and the Plan's rules. The file shows that the eyewear was provided by a non-participating 
provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for eyewear provided on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP services (HCPCS A9279) received from February 15, 
2020 to April 15, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says payment for this service is included in the payment for the base item. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS code A9279 is not supported in the medical record. Specifically, this code is statutorily 
not covered and cannot be billed separately from the CPAP device main code. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for CPAP services (HCPCS A9279) received from February 15, 2020 to April 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on December 6, 2019. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360? and NEXT-Generation?) 
requires use of CPT 81479 (for the entire multi-test panel). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on December 6, 2019.