Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 9, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the knee orthosis (L1833). You say that you would like reconsideration because 
the equipment was medically necessary. The Plan denied your request. The Plan says utilization of network 
providers is required when possible and available. 
 
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 January 9, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum erection device for the enrollee. 
 
You asked the Plan to pre-approve a vacuum erection device. You say that this device is medically necessary.  
The Plan denied your request. The Plan says this device is not covered by Medicare.  
 
The Plan must follow Medicare rules. Medicare rules specifically state the requested device is not covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve a vacuum erection device for the 
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need support stockings to help 
leg swelling. The Plan denied your request. The Plan says you are not using the stockings for the covered 
reasons. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 pre-approve compression 
stockings identified with code A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that you have 
lymphedema and you are needing the leg pump to assist you with the treatment of your condition. The Plan 
denied your request. The Plan says that there was no documentation of trial or failure of an adequate 4 week 
trial of a basic device and there is no documentation of edema extending to the abdomen or trunk. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and sleeves (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit option. 
 
You asked the Plan to pre-approve a transit option. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit option.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench. 
 
You asked the Plan to pre-approve 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 for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a transfer bench.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on January 9, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says codes 99285 and 93042 were denied because they were reported with a secondary 
diagnosis code of T50.905A (under category T50) and did not include the appropriate primary diagnosis code 
or first listed or principal diagnosis code which is required by Medicare.   
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim cannot be paid as billed 
because the primary diagnosis code was omitted. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil 5mg tablets. 
 
You asked the Plan to pre-approve Tadalafil. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this medication is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil 5mg tablets.  
 
Benefits for Tadalafil 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $350 copayment charged for inpatient care provided from 
August 18, 2020, to August 19, 2020. 
 
You asked the Plan to waive this copayment. You say that you were not there a whole day and night and do not 
feel like you should owe this copayment. The Plan denied your request. The Plan says this copayment was 
charged based on the services provided and the Plan contract. The Plan paid $23,074.86 for this service. The 
$350 copayment is your contractual obligation. 
 
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 $350 
copayment for inpatient care per day. 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 $350 copayment charged for inpatient care 
provided from August 18, 2020, to August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for an oral appliance with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for an oral appliance with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on 
August 13, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the provider is question is not in network and there was no 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 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 physician services provided to the enrollee out of network on 
August 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 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 services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that procedure code 20610 was billed with an 
inappropriate diagnosis code. The services must be billed with a diagnosis code indicating the correct 
anatomical site. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on 
June 15, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for ConfirmMDx for prostate cancer epigenetic molecular assay testing 
provided on July 27, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and neither the 
ordering physician nor the enrollee had a choice as to where the specimen was sent. The Plan denied your 
request. The Plan says that the denial of payment for this testing is correct, because the enrollee did not meet 
the criteria for coverage of this test. 
 
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. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this 
testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for 
ConfirmMDx for prostate cancer epigenetic molecular assay testing provided on July 27, 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 the physician services provided by an 
out of network provider. 
 
You asked the Plan to pay for the physician services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request 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 has network providers 
available who can provide the services 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 these services. Therefore, we decided that the 
Plan does not have to pay for the physician services provided by an out of network 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 29, 
2020, to February 2, 2020. 
 
You asked the Plan to pay for the acute inpatient level of care. You say that you need an appeal because the 
plan is responsible to pay for anything on February 1, 2020. The Plan denied your request. The Plan says the 
enrollee's coverage was not in effect at the time of service. 
 
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 for the acute inpatient hospital care provided 
from January 29, 2020, to February 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 gene analysis. 
 
You asked the Plan to pre-approve F2 gene analysis (81240). You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that F2 and F5 genetic tests are not considered to be 
clinically efficacious; therefore, testing is not medically necessary. 
 
We looked at the file and Medicare rules. The requested test is not considered medically necessary. Based on 
this information, we decided that Medicare rules for coverage of F2 gene analysis (81240). have not been met. 
Therefore, we decided that the Plan does not have to pre-approve F2 gene analysis.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Atezolizumab. 
 
You asked the Plan to pre-approve Atezolizumab. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
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 Atezolizumab. Our reviewer says that 
the documentation does support that the requested drug is medically reasonable and necessary. Our physician 
reviewer found the enrollee has small cell cancer urinary bladder. The documentation supports that small cell 
bladder cancer that is nonsurgical and advanced is treated as if it was an extensive stage small cell lung cancer. 
The documentation supports that the requested drug is is safe and effective and otherwise reasonable and 
necessary for this enrollee. Therefore, the enrollee meets criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Atezolizumab have been met. Therefore, we decided that the Plan has to pre-
approve Atezolizumab.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdomen x-ray rendered on July 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 procedure code 74018 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 74018 and 74019. Code 74018 is a column II code with a 
modifier indicator of 1 when billed with column I code 74019. Code 74018 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
abdomen x-ray rendered on July 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
April 11, 2017, to April 13, 2017. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were not aware 
you would be charged a copayment. The Plan denied your request. The Plan says the copayment 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 $325 
copayment per day, for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a total cost share of $650 for the inpatient hospital care (two inpatient days x 
$325). 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 care provided from April 11, 2017, to April 13, 2017.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 27, 
2020, through June 28, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that the service should be 
covered. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for inpatient hospital care.  
 
You have been asked to pay a $200 copayment for inpatient hospital care. This service 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 inpatient hospital care 
provided on June 27, 2020, through June 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the medical services provided on September 
15, 2020. 
 
You asked the Plan to waive the cost share for the services provided. You say that your copay should have been 
$0 for your yearly screening mammogram. The Plan denied your request. The Plan says the claim for the 
diagnostic mammogram and ultrasound processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
The file shows that you received a diagnostic digital tomosynthesis, diagnostic mammogram, and a breast 
ultrasound. You have been asked to pay $193.61 for the services provided. These diagnostic services are not 
covered under the breast cancer screening benefit category The services you asked the Plan to waive the cost 
share for falls within the outpatient hospital services benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $750 deductible This cost sharing is a contractual obligation that 
had not been met at the time the services provided was received on September 15, 2020. Therefore, we decided 
that the Plan does not have to waive the cost share for the medical services provided on September 15, 2020.