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

We decided that the Plan does not have to pay foran eye refraction (92015) provided on March 3, 2020.You asked the Plan to pay forthe eye refraction. You say that you would like reconsideration because the tech did an eye refraction without your permission.The Plan denied your request. The Plan says this service was not rendered by the Plan's designated Routine Vision Care Provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers an annual routine eye exam when provided by the Plan's designatedRoutine Vision Care Provider.We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Specifically, this service was not rendered by the Plan's designatedRoutine Vision Care Provider. Therefore, we decided that the Plan does not have to pay foran eye refraction (92015) provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for DME.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the ophthalmology visit, the visual field 
exam, and the ophthalmic ultrasound you had on April 2, 2019. 
 
You asked the Plan to waive the cost sharing for the ophthalmology visit, the visual field exam, and the 
ophthalmic ultrasound. You say that you should only have to pay the office visit copayment for this visit. The 
Plan denied your request. The Plan says you were charged these copayments 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 $35 
copayment for specialist visits, a $35 copayment for diagnostic eye exams, and a $75 copayment for 
ultrasounds. 
 
You have been asked to pay a $35 copayment for the ophthalmology visit. You were also asked to pay a $35 
copayment for the visual field exam because it is considered a diagnostic eye exam.  In addition, you were 
asked to pay $10.81 (the full allowable amount) for the ultrasound you had, because the allowed amount is less 
than your required $75 copayment for ultrasounds. Plans are permitted to charge multiple copayments if you 
receive multiple services during the same encounter. This means that the Plan has charged this cost sharing 
correctly.  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 cost sharing for the ophthalmology visit, the 
visual field exam, and the ophthalmic ultrasound you had on April 2, 2019.  
 
Please note that this decision only references services rendered on April 2, 2019.  Please contact your Plan with 
any questions you may have about any other dates of service.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the breast (76641) 
provided on December 19, 2019. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 each Medicare-covered diagnostic procedure and test provided in an outpatient facility.  
 
You have been asked to pay a $100 copayment for the Medicare-covered diagnostic test provided. 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 ultrasound of the breast (76641) provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forskilled nursing facility (SNF) services provided from March 2, 2020, through March 27, 2020.You askedthe Plan to waive the copayment forthe SNF services. You say that you thought you wouldn't have a copayment if you left the facility on March 27, 2020. You say that you cannot afford this copayment.The Plan denied your request. The Plan says you were charged this cost sharing 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 $0 copayment for days 1-20 and a $150 copayment per day for days 21-100 for skilled nursing facility services. Records show that you were in the SNF for a total of 25 days.  For the first 20 days, you were not assessed a copayment.  For the last 5 days of your stay, you were assessed a $150 copayment per day for a total of $750. 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 forskilled nursing facility (SNF) services provided from March 2, 2020, through March 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services you received on April 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you are responsible for 
the excess amount. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to the $300 benefit limit. 
 
We looked at the file and the Plan's rules. The Plan only covers eyewear up to $300 per calendar year. You 
must pay any amount in excess of $300. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. Based on this information, we decided that the Plan's rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services 
you received on April 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance transportation provided on January 30, 2019.You asked the Plan to pay forambulance transport. You say that you sent multiple bills to the enrollee with no response.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not filed within the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for ambulance transport was not filed until June 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forambulance transportation provided on January 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit you had with a surgeon (a specialist) on February 12, 2020.You asked the Plan to waive the copayment forthe specialist visit. You say that this copaymentis too high.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 $30 copayment for specialist visits. You have been asked to pay a $30 copayment for the specialist visit. 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 forthe office visit you had with a surgeon (a specialist) on February 12, 2020.Please note that this decision only pertains to the office visit copayment for date of service February 12, 2020.  Your health plan is handling your requests for cost sharing related to drugs you received separately.  Please contact yourPlan with any questions you may have about your request for these items.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on June 15, 2020 to June 
18, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The provider submitted a 
claim for procedure codes 99203 (office visit), 97140 (manual therapy techniques), 97032 (electrical 
stimulation), and 97010 (hot or cold packs therapy). These services are not covered when performed by a 
chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on 
June 15, 2020 to June 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the 
enrollee's treatment has been completed. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services beyond October 1, 2020, were requested for the enrollee. We asked our physician reviewer 
to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pre-approve continued services. Our physician reviewer found that active treatment was 
not taking place. The services were not reasonably expected to improve the enrollee's condition, or for the 
purpose of diagnosis. Based upon review the records, the enrollee was not shown to be a danger to herself or 
others. She was not showing any auditory or visual hallucinations. She was cooperative/compliant with 
treatment while not showing any threats the safety while awaiting placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 26, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the wound care (97597). You say that you would like reconsideration because 
this provider is contracted with the Plan. The Plan denied your request. The Plan says utilization of network 
providers is required unless the Plan pre-approves out-of-network services in non-emergent situations. 
 
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 the medical services provided on June 26, 2020 by 
an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee requires weekly cast 
changes. The Plan denied your request. The Plan says the enrollee has exhausted her benefits. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on the information provided, we 
decided that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided December 18, 2019.You asked the Plan to pay forthe acute inpatient level of care. You say that please see attached documentation that proved you sent medical records back in 03/27/2020 and 04/30/2020.The Plan denied your request. The Plan says the enrollee's admission date of 11/20/2019 is prior to their enrollment with the Plan.The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, the new Plan is not responsible for inpatient hospital care until after the date of discharge. A different health plan was not the Plan of record at the time of the inpatient stay at issue in this appeal began. This means that the new plan is not responsible for coverage of inpatient hospital services until after this stay ended.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided December 18, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management provided on December 
31, 2019. 
 
You asked the Plan to pay for hospital discharge day management. You say that hospice coverage didn't begin 
until December 31, 2019. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
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 hospital discharge day management provided on December 
31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found that the enrollee was admitted to the current acute care hospital with a urinary tract infection, 
sepsis, COVID pneumonia, and altered mental status. She was also diagnosed with dysphagia and 
encephalopathy. She was treated with conservative treatment, Remdesivir, antibiotics, Dexamethasone, and 
high flow oxygen. NG tube feeds were initiated, antibiotics completed, and plans for oxygen weaning and PEG 
were made. The enrollee requires additional short-term acute care services until she is more stable for 
discharge. Ongoing care at the current facility appears most appropriate. She does not require services at the 
LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fit right extra briefs. 
 
You asked the Plan to pre-approve the incontinence supplies. You say that this is medically necessary. The 
Plan denied your request. The Plan says the fit right extra briefs are not durable medical equipment, but 
hygienic equipment, not reusable and not primarily medical in nature 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve fit right extra briefs.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you have no other ride. The Plan 
denied your request. The Plan says the requested services is not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 40 one-way trips per year.  
 
The documentation shows that 3 routine transportation trips were requested. The Plan approved 2 trips. We 
looked at your request, the records in the case file, and the rules. Once you have used the 2 plan-approved trips, 
you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cabometyx 20mg tablets. 
 
You asked the Plan to pre-approve the Cabometyx tablets. You say that this medication is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this oral anti-cancer drug is not among those 
covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 
This oral anti-cancer drug does not have an injectable formulation which means it cannot be covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cabometyx 20mg tablets.  
 
Benefits for the Cabometyx tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invega Sustenna 234 mg/1.5ml for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription 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 pre-approve Invega Sustenna 234 
mg/1.5ml for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you would like to find a closer doctor. The Plan 
denied your request. The Plan says the services are available within the network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We were able to confirm that the Plan has 
contract providers located within reasonable distance and travel time from your home who can provide the 
services at issue. We found no exception that would require the Plan to pre-approve these services. Therefore, 
we decided that the Plan does not have to pre-approve pain management services to be provided by an out of 
network (OON) provider.