Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breathing capacity diagnostic test 
provided on August 3, 2020. 
 
You asked the Plan to waive the copayment for the breathing capacity diagnostic test. You say that you feel 
you should not be responsible for this cost share amount and you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says you received a breathing capacity diagnostic test on the 
date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract 
with the Plan. 
 
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 $45 
copayment for Specialty Physician for other Medicare-covered outpatient diagnostic tests.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a breathing 
capacity diagnostic test on August 3, 2020. You have been asked to pay a $45 copayment for the breathing 
capacity diagnostic test. The breathing capacity diagnostic test falls within the Outpatient diagnostic tests 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the breathing capacity diagnostic 
test provided on August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 15, 2020. 
 
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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in the patient's home and should 
have been billed with POS code 12. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 15, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that it is not safe for you to go home yet. You say 
that you are still experiencing difficulty with aphasia deficits. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval of SNF care. 
 
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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to an acute 
hospital on December 4, 2020, with an acute stroke with right sided hemiparesis, dysarthria and dysphagia. She 
was treated in the hospital and then transferred to an acute rehabilitation facility. She is weak on the right side 
and continues with dysarthria and dysphagia and she is working with speech, physical and occupational 
therapies in the rehabilitation facility. She is walking 250 feet with a front wheeled walker with contact guard 
to minimal assistance and is minimal assist for transfers and minimum to moderate assist for activities of daily 
living. There is no report of any acute unstable medical conditions. The enrollee does not require the necessary 
skilled services on an inpatient basis in a SNF setting. The medical records provided do not show that the 
enrollee specifically requires services in a SNF setting. Continued services in the acute inpatient rehabilitation 
facility appear appropriate in this case until the enrollee is stable for transfer back to her home with home 
health 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on August 15, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you do not believe you should be 
responsible for the copayment because you returned to the ER only to get a new medication. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing 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 $25 
copayment for each emergency room visit.  
 
You have been asked to pay a $25 copayment for the ER visit. The ER visit falls within the 'Emergency Care' 
benefit category. The record shows this visit is considered a separate visit and therefore, a new copayment 
applies. 
 
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 ER visit provided on August 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection services rendered on July 27, 
2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance was applied 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% of 
the total cost for Medicare-covered Part B prescription drugs, including chemotherapy drugs.  
 
Review of the file shows that you received injection services on July 27, 2020. You have been asked to pay 
20% of the total cost for these services. These services fall within the Medicare-covered Part B prescription 
drugs, including chemotherapy drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the injection services rendered on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for retinal imaging provided on August 26, 2020. 
 
You asked the Plan to pay for the retinal imaging. You say that your eye doctor ordered the retinal imaging for 
the future care of your eyes and vision. The Plan denied your request. The Plan says that the services are not 
covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the retinal imaging by a contract provider. The file does not show that the Plan provided 
notice that the retinal imaging would not be covered prior to the services being rendered. Under Medicare rules, 
this means the retinal imaging is considered approved by the Plan. Therefore, we decided that the Plan has to 
pay for retinal imaging provided on August 26, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services from an out of network provider or reimburse 
you for eyeglasses purchased on August 17, 2020. 
 
You asked the Plan to pay for vision services from an out of network provider and reimburse you for the 
eyeglasses purchased from a provider not certified by Medicare. You say that you were aware the provider is 
out of network but thought you could be reimbursed. The Plan denied your request. The Plan says the eyeglass 
provider is not a certified Medicare provider and you did not have authorization for the out of network vision 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. 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 provide care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. The rules say also say that no Medicare payment 
may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare 
payment. 
 
The vision service 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 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 vision services from an out of network provider or reimburse you 
for eyeglasses purchased on August 17, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from April 10, 2020 to April 
28, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that an itemized bill was not provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan is denying payment for the inpatient services because the 
provider did not provide an itemized bill. The case file contains a UB claim form. The Plan has not provided 
any documentation based on Medicare criteria that the claim cannot be reviewed without an itemized bill. We 
find that the Plan has not provided sufficient documentation to support their reasoning for denial of payment. 
Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from April 10, 2020 
to April 28, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited re-evaluation (D0170) provided 
on March 30, 2020. 
 
You asked the Plan to pay for the problem focused limited re-evaluation. You say that you did not receive this 
examination. The Plan denied your request. The Plan says this service is not covered under your benefit plan. 
 
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 
problem focused limited re-evaluation (D0170) provided on March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental crown with dental code D2740 provided on 
October 15, 2020. 
 
You asked the Plan to pay for dental code D2740. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the dental crown with dental code D2740 is not 
covered under your supplemental dental benefit. 
 
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 dental crown with dental code 
D2740 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the dental crown with dental code D2740 provided on October 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal/sinus endoscopy (31267) provided on July 2, 2020. 
 
You asked the Plan to pay for the endoscopy. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation does not support the service billed. 
 
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 31267 is nasal/sinus endoscopy, surgical, with maxillary 
antrostomy; with removal of tissue from maxillary sinus. 
 
We asked our coder 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 the endoscopy. Our reviewer says that CPT code 31267 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provide 
do not include sufficient documentation to corroborate a nasal/sinus endoscopy, surgical, with maxillary 
antrostomy; with removal of tissue from maxillary sinus was performed on July 2, 2020. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the endoscopy have not been met. Therefore, we decided that the Plan does not 
have to pay for the nasal/sinus endoscopy (31267) provided on July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission beyond 1/11/21. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services received after 1/11/21 could have been delivered in an 
outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was medically stable and her condition continued to improve. She was 
discharged home on 1/13/2021. The review has determined that the record showed that at the time of inpatient 
admission the admitting physician did not reasonably expect that the enrollee's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient admission beyond 1/11/21.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not know you 
would have to pay an additional $200. The Plan denied your request. The Plan says the copayment has applied 
correctly in this case. 
 
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 $200 
copayment per day for days 1-5, $0 copayment after day five for inpatient hospital care.  
 
You have been asked to pay a $400 copayment for the inpatient hospital stay (two days x $200 copayment). 
The services provided fall within the inpatient hospital 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 the inpatient hospital stay provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, Pembrolizumab, 
Fosaprepitant IV, Ondansetron IV and Dexamethasone for the enrollee. 
 
You asked the Plan to pre-approve these drugs. You say that these drugs are medically necessary. The Plan 
denied your request. The Plan says that this treatment is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 these drugs. Our reviewer says that that 
these drugs are not medically reasonable and necessary for the enrollee. The combination of drugs requested is 
not FDA approved for use after progression on previous Keytruda. The requested use is not supported in any of 
the CMS approved compendia. There are no supporting citations in a PubMed search. The use is not listed as 
not indicated, not recommended or not supported in any of the compendia. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for these drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these drugs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Carboplatin, Pemetrexed, Pembrolizumab, Fosaprepitant IV, Ondansetron IV and 
Dexamethasone for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
June 20, 2020, to June 25, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like this 
amount reconsidered because you only went to the hospital since it was a matter of life or death. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 $500 
copayment per in-network inpatient hospital admission.  
 
You have been asked to pay a $500 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the ?Inpatient hospital 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 
the inpatient hospital stay provided from June 20, 2020, to June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis (L3670) rendered by the out-of-
network (OON) provider on May 1, 2020. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no 
exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to 
pay for the shoulder orthosis (L3670) rendered by the out-of-network (OON) provider on May 1, 2020.