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

 
We decided that the Plan does not have to waive the copayment for computed tomographic angiography, neck, 
with contrast material(s), including noncontrast images, if performed, and image postprocessing (70498TC) on 
May 1, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that the provider advised you the services 
would be approved by the Plan. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received a computed tomographic angiography, neck, with contrast on May 1, 
2020. The Medicare-allowed amount for the advanced imaging service is less than the set $225 copayment; 
therefore, you have been asked to pay the lesser amount of $163.20 for the advanced imaging. 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 computed tomographic angiography, neck, with contrast material(s), 
including noncontrast images, if performed, and image postprocessing (70498TC) on May 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Protonix. 
 
You asked the Plan to pre-approve Protonix. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Protonix.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650), a wrist-hand orthosis 
(L3916), and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on March 11, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the submitted delivery ticket and proof of delivery indicates different date. Therefore, 
the billed supply code cannot be verified 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery records which support medical necessity for the supplies 
provided in this case. The submitted delivery ticket and proof of delivery indicates different date. Therefore, 
the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis (L0650), a wrist-hand orthosis (L3916), and a shoulder-hand-wrist orthosis (L3960) 
provided to the enrollee on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on 
January 4, 2020. 
 
You asked the Plan to pay for the drug testing. You say that the codes are supported by the physicians custom 
profile. The Plan denied your request. The Plan says the documentation did not include a valid physician order 
or medical records stating exactly what tests are to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We find that the testing at issue is not supported in the medical record. The documentation does not show that 
the test was individualized to identify specific non-prescribed medications or illicit substances. The records 
provided do not document concerns based on clinical review and judgement. This testing is not covered for 
screening purposes. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing 
provided on January 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 13, 
2020 through January 22, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your 
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim 
was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received inpatient hospital care from January 13, 2020 through January 22, 
2020. You are asked to pay a $200 copayment for the inpatient hospital care. Your EOC states that enrollees 
must pay a $200 copayment per admission for inpatient hospital care. 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 inpatient hospital care from January 13, 2020 through January 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omeprazole 40mg tablets. 
 
You asked the Plan to pre-approve Omeprazole. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage for this drug is not available under the Part B Medical Benefit. 
 
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 Omeprazole 40mg tablets.  
 
Benefits for Omeprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you did not go to the 
hospital nor were you transported by ambulance. You say that it was noted that you did not suffer any broken 
bones and you did not require a visit to the hospital. You stated that you would like to appeal the Plan's 
decision and you asked the Plan to reconsider providing coverage. 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 February 15, 2020. 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 services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on May 20, 2019. 
 
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians 
custom profile. The Plan denied your request. The Plan says the documentation did not include a valid 
physician order or medical records. 
 
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 G0480 is definitive drug testing for 1-7 drug classes. We 
find that CPT code G0480 is not supported in the medical record. There were insufficient records that show the 
tests were needed to identify specific substances that were inadequately detected by a presumptive drug test. 
There is no documentation that shows the test was individualized to specific non-prescribed medications or 
illicit substances. The records provided do not document concerns based on clinical review and judgement. 
 Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on May 
20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of benralizumab (Fasenra). 
 
You asked the Plan to pre-approve Fasenra. You say that the enrollee will benefit from this therapy. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does 
not meet the criteria that defines severe eosinophilic asthma. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Fasenra. Our reviewer says that the 
enrollee does not meet the Medicare criteria for use of Fasenra. Our physician reviewer found the enrollee is 
noted to have asthma which was assessed to be of moderate severity. Recent laboratory studies show a normal 
eosinophil count. This drug is indicated for the treatment of severe eosinophilic asthma. Therefore, the 
documentation does not show that the enrollee has a medically accepted indication for use of Fasenra. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fasenra have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of benralizumab (Fasenra).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on September 9, 2019 to 
September 18, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you have been going to this chiropractor for 
years. You say that no one notified you that they were no longer in-network. 
 The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are 
in-network providers available for these services. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic services provided on September 9, 
2019 to September 18, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care from March 2, 2020 through 
March 31, 2020. 
 
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received SNF care from March 2, 2020 through March 31, 2020. There were 
no copay charges for the first 20 days and you are asked to pay a $165 copayment per day for SNF care for the 
10 days. Your EOC states that enrollees must pay a $0 copayment per day for days 1-20, a $165 copayment per 
day for days 21-100 for SNF care. 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 SNF care from 
March 2, 2020 through March 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services from February 25, 2020 
through April 3, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share 
responsibility for the services you received due to the quality of care. The Plan denied your request. The Plan 
says the claims were processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on February 25, 2020 and discharged on March 4, 2020. You 
were asked to pay a $275 copayment per day from February 25, 2020 through March 1, 2020, days 1-6 of your 
inpatient stay. There were no copayment charges from March 2, 2020, day 7 of your inpatient hospital care 
until your day of discharge March 4, 2020. Per your contract there is a $275 copayment per day required for 
days 1-6.  
 
 
 
 
 
Furthermore, you were admitted on March 5, 2020 and was discharged on April 3, 2020. There were no copay 
charges for the first 20 days. You are asked to pay a $178 copayment per day, days 21 through 100 for SNF 
care. 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 services from February 25, 2020 through April 3, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 23, 2020. 
 
You asked the Plan to pay for the office visit. You say that the enrollee has not seen two providers in this group 
with the same taxonomy within the past three years. The Plan denied your request. The Plan says Medicare 
rules for payment of this claim has not been met. 
 
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 99203 is Office or other outpatient visit for the evaluation 
and management of a new patient. We looked at the file and the rules. The documentation shows that the 
enrollee received a new patient office visit on the date of service at issue. The enrollee previously received 
physician services from the same medical group on January 2, 2020. A new patient visit cannot be billed within 
3 years of professional services provided by the same physician group practice. Based on this information, we 
decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the 
Plan does not have to pay for the office visit provided on January 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomographic angiography, chest 
(noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing 
provided on April 14, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that the provider advised you the services 
would be approved by the Plan. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received a computed tomographic angiography, chest on April 14, 2020. The 
Medicare-allowed amount for the advanced imaging service is less than the set $225 copayment; therefore, you 
have been asked to pay the lesser amount of $160.59 for the advanced imaging. 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 computed tomographic angiography, chest (noncoronary), with contrast material(s), 
including noncontrast images, if performed, and image postprocessing provided on April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that these specimens were sent to you. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
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 lab work provided on April 8, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on May 8, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on December 23, 2019. 
 
You asked the Plan to pay for the ophthalmological services. 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 
services at issue. 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 ophthalmological services provided on December 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from March 9, 2020 to 
March 11, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you are appealing 3 charges on your 
hospital bill. The Plan denied your request. The Plan says your medical benefit does not cover self-
administered drugs. 
 
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 pay for the self-administered drugs 
provided from March 9, 2020 to March 11, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 2, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and 
approved for services. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on January 2, 2020 
by an out of network (OON) provider.