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

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available, and platelet-rich plasma injections are considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the available low quality to good quality studies on the subject of platelet-rich plasma injection 
to hip osteoarthritis joints, it suggests it is no better than placebo saline injections. Therefore, without more 
significant supportive evidence to support this treatment in this clinical situation, they will be considered not 
medically 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a platelet rich plasma injection.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says coverage criteria was not met. 
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record 
supports a need for physical and occupational therapy but it does not support a need for an intensive 
rehabilitation therapy program. 
 
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: 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 Skilled Nursing Facility. You say that SNF services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Skilled Nursing Facility. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require 
skilled nursing or therapy services on a daily basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Skilled Nursing Facility have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Skilled Nursing Facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from December 6, 
2019 to December 11, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you 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 $395 
copayment or days 1-4 for inpatient hospital care.  
 
You had an inpatient hospital stay from December 6, 2019 to December 11, 2019. Therefore, you are 
responsible to pay a $395 copayment for days 1-4 (December 6, 2019 to December 9, 2019). $395 (copayment) 
x $395 (copayment) = $1,580.  
 
You have been asked to pay the total copayment amount of $1,580 for an inpatient hospital stay. An 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 an inpatient hospital stay from December 6, 2019 to December 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injectable drugs you received on May 
15, 2020. 
 
You asked the Plan to waive the coinsurance for the injectable drugs. You say that you didn't understand that 
you would owe this much coinsurance for this drug.  You stated that you are going to have to get these 
injections every 8 weeks and you will die without it. The Plan denied your request. The Plan says you were 
charged this coinsurance 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% 
coinsurance for Medicare Part B covered drugs and injectables.  
 
You have been asked to pay 20% coinsurance for the injectable drugs. The injectable drugs you received fall 
within the Medicare Part B covered 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 injectable drugs you received on May 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 25, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. 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. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
reported with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce your copayment for the urgent care visit you had on June 17, 
2020. 
 
You asked the Plan to reduce your copayment for the urgent care visit. You say that you should only have to 
pay a $20 copayment because you didn't ask for a specialist. 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 $40 
copayment for urgently needed care from any provider other than your Provider of Choice.  
 
You have been asked to pay a $40 copayment for the urgent care visit. The urgent care center where you 
received these services is not your Provider of Choice. 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 your copayment for 
the urgent care visit you had on June 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from February 6, 2020 to 
February 13, 2020. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says that 
generally, the enrollee must receive care from a network provider. In most cases, care received from a non-
network provider will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided from February 6, 2020 to 
February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the 
out of network (OON) provider on January 13, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on 
January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for chiropractic services provided from January 7, 
2020 to April 24, 2020. 
 
You asked the Plan to reimburse you for the chiropractic services. The Plan denied your request. The Plan says 
the services were not emergent/urgent, not authorized, and 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 reimburse you 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 
chiropractic services. We found no exception that would require the Plan to reimburse you for these services. 
Therefore, we decided that the Plan does not have to reimburse you for chiropractic services provided from 
January 7, 2020 to April 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid and fitting provided on May 18, 2020.

You asked the Plan to pay for the hearing aid and fitting. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the hearing aids you purchased are not specific hearing aids and are not covered by the Plan.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided through a specific provider.  In this case, the hearing aids purchased are not specific hearing aids. Based on this information, we decided that the Plan's rules for coverage of the hearing aid and fitting have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid and fitting provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on March 27, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration because 
this supply was medically necessary. The Plan denied your request. The Plan says the documentation submitted 
did not include an itemized billing/shipping invoice to verify the billed supplies or a proof of delivery for the 
billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized billing/shipping invoice to validate the billed supplies. Additionally, the 
delivery ticket includes a different date of service than what was billed. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for lumbar-sacral orthosis (L0650) provided on March 27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
March 28, 2019. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you shouldn't have to pay this 
copayment since you didn't get a bill for it for more than a year after the services. The Plan denied your request. 
The Plan says you were charged this copayment correctly.  The plan says that you were first advised of this 
copayment obligation on an Explanation of Benefits (EOB) they sent you on April 16, 2019. The ER sent in 
corrected claims to the plan on November 13, 2019 and June 9, 2020.  The Plan sent you EOBs on each of 
these days too, advising you of the copayment obligation, so you were on notice that you owed this 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 $100 
copayment for emergency care.  
 
You have been asked to pay a $100 copayment for the ER visit. This cost sharing applies regardless of how 
long it takes the facility to send a bill to you. 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 
emergency room (ER) visit you had on March 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on March 7, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 7, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 
7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mammogram you had on December 13, 
2019. 
 
You asked the Plan to waive the copayment for the mammogram. You say that you should not have a 
copayment for a screening mammogram. The Plan denied your request. The Plan says you were charged this 
copayment correctly. You had your routine screening mammogram on December 4, 2019. for which you were 
not charged a copayment.  You then returned for a diagnostic mammogram and breast tomosynthesis on 
December 13, 2019.  This second, diagnostic mammogram requires a copayment. 
 
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 $15 
copayment for x-ray services.  
 
You have been asked to pay a $15 copayment for the mammogram. This second diagnostic mammogram is an 
x-ray service. You had already received your fully covered screening mammogram on December 4, 2019. 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 mammogram you had on December 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 93010 provided on March 30, 2020. 
 
You asked the Plan to pay for CPT code 93010. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when necessary the appropriate modifiers. In this 
case, the claim submitted should have been submitted with modifier 77 to be paid correctly. Medicare billing 
criteria were not met. Therefore, we decided that the Plan does not have to pay for CPT code 93010 provided 
on March 30, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the additional copayment applied to the application of a multi-layer 
compression system to the leg during an occupational therapy visit provided on March 12, 2020 billed with 
code 29581-GO. 
 
You asked the Plan to waive the additional copayment applied to the compression system application... You 
say that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the 
occupational therapy plan of care and is billed as such. The Plan denied your request. The Plan says that a 
specialist service copayment was correctly applied to code 29581. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a 
$40 copayment for Medicare-covered occupational therapy visits. 
 
The Plan says the enrollee must pay an additional $45 copayment for specialist services provided on this date 
of service. However, based on the contract, the enrollee cannot be asked to pay more than a $40 copayment for 
a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed 
as part of the occupational therapy plan of care. There is no language in the contract which would create a 
reasonable expectation that an additional copayment would be applied to a service provided during an 
occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this 
service as it appears this care would have been rendered by the same provider who performed the manual 
therapy. Therefore, we decided that the Plan has to waive the additional copayment applied to the application 
of a multi-layer compression system to the leg during an occupational therapy visit provided on March 12, 
2020 billed with code 29581-GO.  
 
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 waive the coinsurance for the leg prostheses you received from April 
19, 2019 through March 31, 2020. 
 
You asked the Plan to waive the coinsurance for the leg prostheses. You say that you were not aware there 
would be a copayment.  You also said that you shouldn't have to pay for this service the equipment doesn't 
work for you properly. The Plan denied your request. The Plan says you were charged this coinsurance 
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% 
coinsurance for prosthetic devices and supplies.  
 
You have been asked to pay 20% coinsurance for the leg prostheses. the leg prostheses falls within the 
prosthetic devices 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 coinsurance for 
the leg prostheses you received from April 19, 2019 through March 31, 2020.  
 
Your complaint about the prosthesis not working correctly for you is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.