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

We decided that the Plan does not have to pre-approve Xifaxan tablets. 
 
You asked the Plan to pre-approve Xifaxan tablets. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 
plan. 
 
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 Xifaxan tablets.  
 
Benefits for Xifaxan tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist x-ray rendered on March 5, 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 73110 is not supported. 
 
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 73110 is radiologic examination, wrist; complete, 
minimum of 3 views. 
 
We find that CPT code 73110 is not supported in the medical record. Specifically, there is no interpretation 
report of a wrist x-ray with three views. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
wrist x-ray rendered on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit (G0463) 
provided on June 1, 2020. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you were not 
informed about this charge. The Plan denied your request. The Plan says this processed 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 $300 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $110.28 copayment for a hospital outpatient clinic visit because the allowed 
amount is less than $300. 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 a hospital outpatient clinic 
visit (G0463) provided on June 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTAC 
services. The Plan denied your request. The Plan says criteria for admission to a LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. Our reviewer found that there are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0651) and accessories 
(E0667) provided on August 10, 2020. 
 
You asked the Plan to pay for a pneumatic compression device and accessories. You say that this was 
medically necessary. The Plan denied your request. The Plan says a sufficient trial of conservative therapy was 
not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0650 or E0651 is covered for 
the treatment of chronic venous insufficiency (CVI) of the lower extremities only if the ulcer(s) have failed to 
heal after a six-month trial of conservative therapy directed by the treating practitioner. 
 
We looked at the file and Medicare rules. The submitted medical records do not document a trial of 
conservative therapy as described above. Based on this information, we decided that Medicare rules for 
coverage of a pneumatic compression device and accessories have not been met. Therefore, we decided that the 
Plan does not have to pay for a pneumatic compression device (E0651) and accessories (E0667) provided on 
August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient care you received from 
October 1, 2019, to October 5, 2019. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says the claim processed 
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 $372 
copayment per day for days 1-5 for inpatient hospital care.  
 
Review of the file shows that you were provided 4 days of inpatient hospital care from October 1, 2019, to 
October 5, 2019. You have been asked to pay a $372 copayment per day for the services, totaling $1,488. The 
services 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 care you received from October 1, 2019, to October 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you have 
not completed the full course in the hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found that you presented to the hospital for respiratory issues. You still require acute hospital level of 
care services, and are receiving appropriate care at the present acute care hospital You do not require services 
at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are 
no services available at the LTACH that you require that are not available at the health care setting being 
offered by the health plan. Therefore, the requested LTACH services  are not medically necessary or reasonable 
at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services from August 3, 2020, 
to August 15, 2020. 
 
You asked the Plan to pay for August 3, 2020, to August 15, 2020. 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 the enrollee's therapy needs could have been met at a lower level of care. 
The Plan says also says that the enrollee did not receive any nursing services from August 3, 2020, to August 
15, 2020. 
 
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 August 3, 2020, to August 15, 2020. 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 August 3, 2020, to August 15, 2020 have not been met. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) services from August 3, 2020, to August 
15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 18, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services were not referred by a network provider or rendered in a participating 
facility and 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 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 the medical services provided on March 18, 2020, 
by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lead wires provided on September 4, 2020. 
 
You asked the Plan to pay for lead wires (A4557). You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says the TENS unit has been purchased in the previous 12 months and the records do 
not support the medical necessity of the additional lead wires. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The TENS device was provided on April 4, 2020 and there is no 
documentation supporting why lead wires are needing replacement before 12 months time. Based on this 
information, we decided that Medicare rules for coverage of lead wires (A4557) have not been met. Therefore, 
we decided that the Plan does not have to pay for lead wires provided on September 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 15, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after 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 the services was not filed until August 28, 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 the services provided on June 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 28, 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 May 28, 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 on May 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ultrasounds rendered on August 31, 
2020 and September 15, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were 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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays.  
 
Review of the file shows that you received two ultrasounds on August 31, 2020. You have been asked to pay a 
$110 copayment per ultrasound for these services, for a total of $220. These services fall within the Medicare-
covered radiological diagnostic service, not including x-rays benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan.  
 
The file shows that you received an ultrasound on September 15, 2020. Per the contract with the Plan, there is a 
$110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays. However, the 
Medicare allowed amount for these services was $91.33. Given that the allowed amount was less than the $110 
copayment, you have been asked to pay $91.33 for these services. 
 
The total amount you have been asked to pay for these services is $311.33. 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 copayments for the ultrasounds rendered on August 31, 2020 and September 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis tablets. You say that the enrollee has been doing well on this 
medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug plan. 
 
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 Eliquis tablets.  
 
Benefits for Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a stair glide purchased on June 3, 2020. 
 
You asked the Plan to reimburse you for a stair glide. You say that you were told this stair lift would be 
covered by the Plan. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to reimburse you for a stair glide purchased on June 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Denosumab injection (J0897) provided 
on August 11, 2020. 
 
You asked the Plan to waive the coinsurance for a Denosumab injection. You say that you want the plan to pay 
for the Denosumab injection. The Plan denied your request. The Plan says the correct coinsurance was applied.  
 
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 Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for a Denosumab injection. A Denosumab injection falls within 
the Medicare Part B prescription 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 a Denosumab injection (J0897) provided on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the portable oxygen concentrator provided 
on August 19, 2020, to October 19, 2020. 
 
You asked the Plan to waive the copayments for the portable oxygen concentrator. You say that you returned 
the stationary equipment on August 19, 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 20% 
coinsurance for in-network Medicare-covered durable medical equipment and related supplies.  
 
You have been asked to pay $27.35 which is 20% of the allowed amount for the portable oxygen concentrator 
on each date of service. The allowed amount is $136.77. ($136.77 x 20% = $27.35) ($27.35 x 3 dates of service 
= $82.05). The portable oxygen concentrator falls within the ?Durable medical equipment (DME) and related 
supplies? benefit category. The record shows you were billed for the portable oxygen concentrator. 
 
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 copayments for the portable oxygen concentrator provided on August 19, 
2020, to October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
September 23, 2020. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that the specialist 
copayment should not be paid to a physician's assistant. You say the copayment should be lesser. 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 $45 
copayment for each Medicare-covered visit with an in-network specialist.  
 
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 
within the ?Physician/Practitioner services, including doctor?s office visits? benefit category. The record shows 
that the physician?s assistant is considered a specialist practitioner.  
 
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 the copayment for the specialist office visit provided on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided September 2, 
2020. 
 
You asked the Plan to pay for the annual wellness visit. You say that the visit should be covered. The Plan 
denied your request. The Plan says there was another visit the same year billed with the code for annual 
wellness visits. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided 
September 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 June 23, 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 on June 23, 2020.