Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to fully pay for progressive lenses received on October 1, 2020. 
 
You asked the Plan to fully pay for the lenses. You say that this should be paid for. The Plan denied your 
request. The Plan says you have exhausted your vision benefits. 
 
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 with up to a $100 maximum benefit per year. 
 
We looked at the file and the Plan's rules. The cost of the eyewear at issue in this case was more than $100. The 
plan can pay for the first $100 of the claim, but any remaining balance is your responsibility. Based on this 
information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we 
decided that the Plan does not have to fully pay for progressive lenses received on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on April 15, 
2019. 
 
You asked the Plan to pay for psychiatric evaluation. You say that you depend on the facility for timely 
notification of the enrollee's health insurance coverage but did not receive proper notice of this enrollee's 
benefit determination. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because this claim was not submitted 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 psychiatric evaluation was not filed until September 3, 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 for a psychiatric diagnostic evaluation provided on April 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from November 12, 2019, 
through April 7, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services 
were available with in-Plan providers.   
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for physician's services provided from November 12, 2019, through April 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection services rendered from July 
1, 2020 to July 7, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered Part B drug.  
 
Review of the file shows that you received Part B drug injections from July 1, 2020 to July 7, 2020. You have 
been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered Part B 
drug 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. 
The Plan confirmed that you had met $2,282.68 of your $3,900 out of pocket maximum for 2020 at the time 
these claims were processed. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the injection services rendered from July 1, 2020 to July 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care billed with a diagnosis code of Retention of 
urine, unspecified (R33.9) provided on July 9, 2020, to July 13, 2020. 
 
You asked the Plan to pay for the inpatient care. You say that the record supports the DRG as originally billed. 
The Plan denied your request. The Plan says the records do not support the diagnosis code as billed and a 
change in DRG is warranted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG. DRG 695 is defined as Kidney and 
Urinary Tract Signs and Symptoms with Major Complication or Comorbidity.  
 
In this case, you billed the services provided July 9, 2020, to July 13, 2020 with DRG 695. 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 inpatient care. Our reviewer says that the diagnosis code 
retention of urine, unspecified (R33.9) was not supported by the medical records in this case. Our physician 
reviewer found the patient was found to have acute renal failure with tubular necrosis and the focus of 
treatment was on the acute kidney injury, beyond the Foley insertion, the urinary retention was not treated.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate DRG 695. Therefore, we decided that the Plan does not have to pay for the 
inpatient care billed with a diagnosis code of Retention of urine, unspecified (R33.9) provided on July 9, 2020, 
to July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient hospital care pending skilled nursing facility 
(SNF) placement. 
 
You asked the Plan to pre-approve the continued inpatient care. You say that the Plan has not been able to 
assist with finding an out of network SNF, and all in-network SNFs are unable to accept the enrollee. She 
cannot be placed in any other level of care. The Plan denied your request. The Plan says that the enrollee no 
longer meets inpatient criteria. The hospital cannot be paid to care for the enrollee pending SNF placement. 
 
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. The rules also require Plans 
to arrange care out of network when in-network providers are inadequate or inaccessible.  
 
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 continued inpatient care. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the hospital with severe debility due to alcohol abuse. 
She is in need of extensive physical therapy. She has now tested positive for COVID and needs SNF 
placement. Bed availability for COVID patients is limited, and no network SNFs are able to accept the 
enrollee. The hospital staff have not been able to communicate with the Plan to get an approval for an out of 
network facility. 
 
Review of the records show that the enrollee is clearly unable to go home for self-care or with family. SNF is 
required as extensive therapy is needed to return to independence. 
 
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 continued inpatient care have been met. Therefore, we decided that the Plan 
has to pre-approve continued inpatient hospital care pending skilled nursing facility (SNF) placement.  
 
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 pay for a pneumatic compression device (E0675) and an accessory 
(E0673) provided on September 22, 2020. 
 
You asked the Plan to pay for a pneumatic compression device and an accessory. You say that these items were 
medically necessary. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is not eligible for 
reimbursement. If the base PCD is not covered, related accessories are not eligible for reimbursement. 
 
We looked at the file and Medicare rules. The base compression device at issue is not covered. Based on this 
information, we decided that Medicare rules for coverage of a pneumatic compression device and an accessory 
have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression 
device (E0675) and an accessory (E0673) provided on September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 7, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
laboratory services. 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 laboratory services provided on September 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilatory with noninvasive interface 
(E0466RR). 
 
You asked the Plan to pre-approve a home ventilator. You say that you would like the authorization to be 
reconsidered. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for 
authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that there must be sufficient clinical documentation to 
justify the use of a home ventilator vs the home use of bi-pap. 
 
The clinical documentation did not include documentation of respiratory failure, or of failure of bi-pap. The 
documentation indicated the member improved with bi-pap therapy. The documentation would indicate that the 
ventilator is being used as bi-pap. As such, per the NCD, it is not reasonable and necessary  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a home ventilatory with noninvasive interface (E0466RR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevator for the enrollee. 
 
You asked the Plan to pre-approve the enrollee. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not serve a primarily medical purpose. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevator for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF is medically necessary. The Plan denied your 
request. The Plan says rules for SNF care have 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not support that 
skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse 
required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient 
does not have complex wound care that requires a SNF stay. The patient 's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment only in a SNF. Skilled services are not 
needed on a daily basis or as practical matter in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reimburse the cost share for services provided on May 29, 
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 states that at the time this claim processed, a total of $783.00 towards the Medicare MOOP 
had been used. This provider is part of the plan's participating provider organization network and these 
services were discounted according to the negotiated rate. Per page 73-74 of the member?s 2019 Evidence of 
Coverage (EOC), the copayment is $50.00 for advanced radiological services. 
 
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 physician services provided on May 29, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the 15 minutes of intravenous sedation (D9243) provided on March 27, 
2020. 
 
You asked the Plan to pay for the dental service. You say that the provider does have the permits to administer 
this type of sedation. You also say that you are very upset and do not believe that this should have to go 
through the appeal process. The Plan denied your request. The Plan says that the dentist needs to have the 
correct permit to administer this type of anesthesia treatment. The Plan also says that the dentist in this case 
does not have the correct permit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The provider in this case is a contracted provider with the Plan. The file does not show that the enrollee would 
have reasonably had any knowledge of the provider\s licensing prior to receiving the service, therefore the 
enrollee would not have known the dental service would not be covered. Under Medicare rules, this means the 
dental service is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 15 
minutes of intravenous sedation (D9243) provided on March 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided from January 2, 2019 to February 26, 2019.
You asked the Plan to pay for this service. You say that the provider did not tell you he was not a Medicare eligible provider. The Plan denied your request. The Plan says Medicare payment cannot be made to physician who are not Medicare eligible providers.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the Medicare program. The services at issue were provided by a physician who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided from January 2, 2019 to February 26, 2019.
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 rules for IRF care have not been 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: 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 this service is medically necessary. The Plan denied 
your request. The Plan says rules for IRF care have not been 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on September 15, 
2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 diagnostic radiology services provided on September 15, 2020.