Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two removals of torus mandibularis provided on August 
20, 2020. 
 
You asked the Plan to pay for the removals of torus mandibularis. You say that this was major surgery which 
you needed. You also say that you were told these services were covered. The Plan denied your request. The 
Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 two 
removals of torus mandibularis provided on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 7, 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 if no CPT code accurately describes the procedure performed, the laboratory may report CPT 
code 81479. 
 
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 services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services provided to the enrollee on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for outpatient surgery services provided on 
July 23, 2020, at the outpatient department of the hospital. 
 
You asked the Plan to reduce the copayment for outpatient surgery services. You say that you saw the copay 
was $350 instead of $200. 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 outpatient surgery services on July 23, 2020, at the outpatient 
department of a hospital. You are asked to pay a $350 copayment for the outpatient surgery services. Your 
EOC states that enrollees must pay a $350 copayment per date of service for outpatient hospital facility and a 
$200 copayment for ambulatory surgical center for the 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 reduce the 
copayment for outpatient surgery services provided on July 23, 2020, at the outpatient department of the 
hospital.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for air ambulance services provided on July 17, 2020, by a non-
participating provider. 
 
You asked the Plan to pay for air ambulance services. You say that the services were medically necessary and 
reasonable. The Plan denied your request. The Plan says that the services were not medically necessary and 
reasonable. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our physician 
reviewer found the wait time for ground transport availability negates the similarity in the time differences in 
transport claimed by the denial. Our physician reviewer feels that in this instance where the added wait time 
was potentially detrimental to patient outcomes that air ambulance transport was medically reasonable and 
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 air ambulance services have been met. Therefore, we decided that the Plan has 
to pay for air ambulance services provided on July 17, 2020, by a non-participating provider.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the requested items are medically 
necessary. You say that you cannot get any blood from your fingers.  
 
You say that you use blood tests 4 times a day, that your doctor has approved use of the requested item as 
necessary, and that you would like to control your diabetes. The Plan denied your request. The Plan says you 
do not meet the required coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered when 
certain criteria have been met. Medicare rules also say that information must be submitted that confirms 
Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The records provided do not show that you are currently insulin-
treated with 3 or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin 
infusion pump.  Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses provided on September 15, 2020. 
 
You asked the Plan to pay for the contact lenses. The Plan denied your request. The Plan says benefit only 
covers up to the maximum allowed amount with a $125 eyewear allowance (not related to her separate cataract 
surgery benefit). The $125 eyewear benefit was exhausted with this purchase. Specifically, the $125 benefit 
was applied correctly to the   purchase of her contacts (HCPC V2500) and their fitting fee (CPT 92310) as 
billed on this claim. 
 
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 $125 eyewear benefit was exhausted with this 
purchase. The $125 benefit was applied correctly to the purchase of your contacts. Therefore, we decided that the 
Plan does not have to pay for contact lenses provided on September 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 1, 2020. 
 
You asked the Plan to pay for the physician's 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 
members 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 physician's services provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on August 31, 2020. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says an eye refraction 
is not covered under a non-routine office visit. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Plan's rules. Medicare does not pay for procedures performed in the course of any 
eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay 
for an eye refraction provided on 
August 31, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography (sleep study). 
 
You asked the Plan to pre-approve sleep study. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
enrollee does not have a diagnosis that meets coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that polysomnography is only covered if the enrollee 
demonstrates clinical evidence of one or more of the above-listed conditions. 
 
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 sleep study. Our reviewer says that the 
enrollee does not meet the Medicare criteria for polysomnography. Our physician reviewer found there is no 
documentation indicating that the enrollee has any of the diagnoses that meet criteria. Also, Medicare rules 
state that snoring and nasal obstructive signs and symptoms are not, in and of themselves, indications for 
polysomnography. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve polysomnography (sleep study).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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. 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 medical services provided to the enrollee by an out-of-network provider 
on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the fundus photography provided on October 6, 
2020 as part of a routine eye exam. 
 
You asked the Plan to reimburse you for the fundus photography. You say that you do not feel that you should 
have had to pay for this service when the office refused to do the dilation. The Plan denied your request. The 
Plan says the denied service is not covered as part of a routine exam. 
 
The Plan must follow Medicare rules. Medicare rules say that fundus photography is not covered if done for 
screening. The contract with the Plan does not indicate that this service is covered.  
 
In this case, you agreed to pay out of pocket for this service. The provider did not indicate that this would be 
covered by your Plan. As Medicare does not cover this as a screening service, the denial of payment is 
appropriate.  
 
Therefore, we decided that the Plan does not have to reimburse you for the fundus photography provided on 
October 6, 2020 as part of a routine eye exam.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 enrollee's medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. 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 documentation does not support that the enrollee requires 
an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on July 8, 2020. 
 
You asked the Plan to pay for initial hospital care. You say that the services should be covered. The Plan 
denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is two annual deductibles for certain medical services; $198 medical 
deductible per plan year for most Part B in-network and out-of-network services and $1,408 deductible per plan 
year for most Part A in-network and out-of-network services. 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is two annual deductibles 
for certain medical services; $198 medical deductible per plan year for most Part B in-network and out-of-
network services and $1,408 deductible per plan year for most Part A in-network and out-of-network services. 
This cost sharing is a contractual obligation that had not been met at the time initial hospital care was received 
on July 8, 2020. Therefore, we decided that the Plan does not have to pay for initial hospital care (99223) 
provided on July 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy (43235, 45380) provided on 
July 27, 2020. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that this was not an elective surgery. 
The Plan denied your request. The Plan says this processed 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 $250 
copayment for Medicare-covered surgical services.  
 
You have been asked to pay a $250 copayment for an endoscopy, which is a Medicare-covered surgical 
service. 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 endoscopy (43235, 45380) provided on July 
27, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to her poor endurance and exercise tolerance. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan 550MG tablet. 
 
You asked the Plan to pre-approve Xifaxan. 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 Xifaxan 550MG tablet.  
 
Benefits for Xifaxan 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for pacemaker battery replacement received 
on October 2, 2019. 
 
You asked the Plan to adjust the coinsurance for the services. You say that the coinsurance applied for the 
service is considerably higher than the same service received previously. The Plan denied your request. The 
Plan says the coinsurance was applied correctly according to your benefits and the services rendered. 
 
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 outpatient surgical services.  
 
You have been asked to pay 20% coinsurance for the services. The services fall within the outpatient surgical 
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 adjust the coinsurance for pacemaker battery 
replacement received on October 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray provided on September 3, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you did not have a choice as to where to 
have the X-ray and disagree with 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 $110 
copayment for basic radiological services provided in an outpatient hospital facility. 
 
You received an X-ray on September 3, 2020, at an outpatient hospital facility. Therefore, you are responsible 
to pay the allowed amount of $80.32, which is less than the $110.   
 
You have been asked to pay $80.32 for an X-ray. An X-ray 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 X-ray provided on September 3, 2020.