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

 
We decided that the Plan does not have to pay for the custodial care stay provided from July 6, 2020, to August 
4, 2020. 
 
You asked the Plan to pay for the custodial care. You say that the services which the enrollee required and 
received during the dates of service in question are coverable under the Medicare Act. The Plan denied your 
request. The Plan says custodial care provided in a nursing home, hospice, or other facility setting when the 
enrollee does not require skilled medical care or skilled nursing care. The Plan says that the enrollee could have 
been evaluated and treated in a long term care facility. 
 
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 pay for the custodial care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the custodial care have not been met. Therefore, we decided that the Plan does 
not have to pay for the custodial care stay provided from July 6, 2020, to August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for routine venipuncture (36415) provided on 
July 7, 2020. 
 
You asked the Plan to waive the copayment for routine venipuncture. You say that you should not have a copay 
for this service. The Plan denied your request. The Plan says there is a $10 copayment for laboratory tests. 
 
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 $10 
copay for laboratory tests.  
 
You have been asked to pay a $10 copay for routine venipuncture. Routine venipuncture falls within the 
laboratory 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 routine venipuncture 
(36415) provided on July 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole 20 mg tablet. 
 
You asked the Plan to pre-approve Pantoprazole. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this medication does not fall under Part B. 
 
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 Pantoprazole 20 mg tablet.  
 
Benefits for Pantoprazole 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam and panoramic x-rays rendered 
on September 23, 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 exceeded the benefit limits. 
 
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. The Plan covers a 
comprehensive oral exam once every three years and panoramic x-rays once every five years.  
 
The services at issue are a comprehensive oral exam and panoramic x-rays rendered on September 23, 2020. 
The file shows that you previously received these services on February 14, 2020 for which the Plan approved 
and paid. The services on September 23, 2020 were performed less than three years from your previously 
covered exam and less than five years from your previously covered panoramic x-rays. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral exam and panoramic x-rays rendered on 
September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drugs and medicaments (D9630 x 4), pontics 
(D6240 x 4), retainer crowns (D6750 x 4), and bone replacement grafts (D7953 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that it states in your booklet that crowns and 
bone replacement grafts are listed as covered services. You say that you had the same procedures done in 2017. 
You also say that you wake up every morning with blood in your mouth. The Plan denied your request. The 
Plan says the requested services are excluded from coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Additionally, the record shows that the services you received in 2017 
were single tooth crowns which are covered by the Plans supplemental dental benefit. There are no records 
that show you had a bone replacement graft in 2017. Therefore, we decided that the Plan does not have to pre-
approve the drugs and medicaments (D9630 x 4), pontics (D6240 x 4), retainer crowns (D6750 x 4), and bone 
replacement grafts (D7953 x 4).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve the second opinion with an out of network provider. You say that you do not 
want a second opinion with a specialist in the same group where you were already seen. The Plan denied your 
request. The Plan says you have been offered other specialists who are not part of the same group. 
 
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 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 a second 
opinion to be provided by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on January 31, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you continue to get bills 
which show your patient responsibility. You say the bill you received does not show a credit of $109.59 paid 
on April 27, 2020. 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 $300 
copayment for each one-way Medicare-covered ground transportation service.  
 
You have been asked to pay a $300 copayment for the ambulance ride. The ambulance ride falls within the 
'Ambulance services' benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance ride provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the morphometric analysis and special stain (88312 and 88361) 
provided on August 29, 2019. 
 
You asked the Plan to pay for the morphometric analysis and special stain. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that review of the 
medical literature and clinical practice guidelines does not support the clinical utility of testing using computer-
assisted regeneration and immunohistochemistry to predict cancer. Also, there is no documentation in the 
pathology report regarding the need for the special stain. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the morphometric analysis and special stain. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found these tests performed were indicated given diagnosis and need to screen for 
Barrett's esophagus. 
 
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 morphometric analysis and special stain have been met. Therefore, we 
decided that the Plan has to pay for the morphometric analysis and special stain (88312 and 88361) provided on 
August 29, 2019.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit and lab work, provided on July 20, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient clinic visit and lab work. You say that you would like this claim 
reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 had network providers 
available who could have provided 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 an outpatient clinic visit and lab work, provided 
on July 20, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transthoracic echocardiography (TTE) complete with Doppler and color flow without contrast (93306) provided April 10, 2020.

You asked the Plan to waive the copayment for transthoracic echocardiography. You say that you had paid the copay for the visit and is not being charged for the Echo summary. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $35 copayment per visit to a specialist for Physician/Practitioner services, including doctor's office visits. 

You have been asked to pay $35 copayment per visit to a specialist for transthoracic echocardiography. transthoracic echocardiography falls within the Physician/Practitioner services, including doctor's office visits 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 transthoracic echocardiography (TTE) complete with Doppler and color flow without contrast (93306) provided April 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for Physical Therapy services (97161, 97112, 
97140, 97530) received July 8 and July 15, 2020. 
 
You asked the Plan to waive the deductible for physical therapy services. You say that the provider was in-
network and should be fully covered. The Plan denied your request. The Plan says you were advised that you 
had a deductible to meet before physical therapy services would be covered. 
 
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 a $400 deductible for outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$400 deductible for outpatient rehabilitation services. This cost sharing is a contractual obligation that had not 
been met at the time physical therapy services was received on July 8, 2020 and July 15, 2020. Therefore, we 
decided that the Plan does not have to waive the deductible for Physical Therapy services (97161, 97112, 
97140, 97530) received July 8 and July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on July 
13, 2020. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the device was provided during 
the enrollee's surgery at the request of a physician. The Plan denied your request. The Plan says a pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for the pneumatic compression device (E0676) provided on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided. 
 
You asked the Plan to pay for the shingles vaccine. You say that the cost would be a financial hardship. The 
Plan denied your request. The Plan says the service is not covered under Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided.  
 
Benefits for the shingles vaccine 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a therapeutic continuous glucose monitors. 
 
You asked the Plan to provide a therapeutic continuous glucose monitors. You say that your fingers get sore 
from finger stick testing. The Plan denied your request. The Plan says you are not insulin treated and therefore 
do not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin. Based on 
this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitors 
have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous 
glucose monitors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 64483 provided on April 22, 
2020. 
 
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 64483 is injection(s), anesthetic agent and/or steroid, 
transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level. 
 
We find that CPT code 64483 is not supported in the medical record. Specifically, this code was not billed with 
an appropriate anatomical modifier. Based on this information, we decided that Medicare rules for coverage of 
the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the 
injection services coded 64483 provided on April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reimburse the cost share for several claims for services 
provided from January 4, 2019, to February 21, 2019. 
 
You asked the Plan to waive or reimburse funds you believe were overpaid for services provided in 2019. You 
say that you believe you have overpaid the maximum out of pocket (MOOP) for 2019. The Plan denied your 
request. The Plan says the claims in question were reviewed. The Plans portion of the services in question have 
been paid for each service leaving your contractual copayment expectations. 
 
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 in 2019 there was a 
maximum out of pocket of $4500. The Plan has provided claim and payment information for each service in 
question. Both the records and the Explanation of Benefits (that you would also have a copy of ) for each 
service clearly show the balance of the maximum out of pocket at the time of service. You have been asked to 
pay the correct amount for each service 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 or reimburse the cost share for several claims for services provided from January 4, 2019, to February 
21, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from August 29, 2020, 
to September 7, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from August 29, 2020, to September 7, 
2020.