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

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on August 20, 
2019. 
 
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 it has been verified that  the primary insurer payor at the time of service 
and that an explanation of benefits showing they addressed the claim first would be required. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. The Plan has met its obligation with 
regards to coordination of benefits. Specifically, the Plan has identified the primary insurer at the time of 
services. As the secondary insurer, the Plan cannot be held responsible for this service until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for physician services provided to the enrollee on August 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided on July 23, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that you were expecting to pay $90. 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 $295 
copayment for outpatient surgery provided in an outpatient hospital facility.  
 
You have been asked to pay a $295 copayment for an EGD. An EGD falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions. 
 
You asked the Plan to pre-approve the dental extractions. You say that the enrollee requires this treatment due 
to severe tooth decay which if left untreated will damage the bone. If this happens, he will be unable to get the 
implants he requires to eat normally. The Plan denied your request. The Plan says this is not covered by 
Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
dental extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 21, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you are unhappy with the service 
the provider gave you and feel that you should not be responsible for 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 $40 
copayment for specialist services.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on May 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 1, 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 1, 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 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on April 22, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment. You say that you were told that because of COVID-
19 a referral was not needed. The Plan denied your request. The Plan says prior authorization was not obtained. 
The Plan says that there are in-network providers available for these services. 
 
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 durable medical equipment provided on April 22, 
2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from May 1, 
2020 to May 26, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was billed with an incorrect type of bill code (323). The Plan states a 
corrected claim is needed for payment. 
 
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 submitted has an invalid POS 
code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided to the enrollee from May 1, 2020 to May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 19, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that a PC/TC indicator of 8 identifies professional 
component of clinical laboratory codes for which separate payment may be made only if the physician 
interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 85060. This code 
has a PC/TC indicator of 8 and was not performed in an inpatient hospital setting. No payment can be made for 
this code as billed. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on March 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.

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 specialist services provided on March 12, 2020 by an out of network (OON) provider
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee on March 
10, 2020. 
 
You asked the Plan to pay for home health services. You say that this was billed with correct diagnosis and 
revenue codes. The Plan denied your request. The Plan says this was billed without a valid HIPPS code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim is 
missing a valid HIPPS code. Therefore, we decided that the Plan does not have to pay for the home health 
services provided to the enrollee on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction provided on May 19, 2020. 
 
You asked the Plan to pay for refraction. You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says you received a medical vision check therefore the claim processed correctly. 
 
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.  
 
We looked at the file and the Plan's rules. Refraction is not separately reimbursed as part of a medical 
examination and evaluation with treatment/diagnostic program. Based on this information, we decided that the 
Plan's rules for coverage of refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for refraction provided on May 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there is no expectation of functional improvement in reasonable time 
period. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you require more therapy. The Plan denied your 
request. The Plan says that you no longer require skilled services. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. 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 you do not require the intensity of services provided at an IRF. Specifically, you have 
not been shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvethe requested bed. You say that the enrollee's wife is unable to assist him properly without the ability to adjust the bed.The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare or the plan.The Plan must follow Medicare rules. Medicare rulessay that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Superion interspinous spacer device.You asked the Plan to pre-approvethe Superion interspinous spacer device. You say that the records provided support the need for the requested device.The Plan denied your request. The Plan says the requirements for approval have not been met. The Plan says that the current medical literature indicates that the requested procedure is considered experimental and investigational, as it is not yet identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published.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 Superion interspinous spacer device. Our reviewer says that the Superion interspinous spacer device is not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental. More research is needed to show its safety and efficacy.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 Superion interspinous spacer device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Superion interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a water circulating heating pad with pump coded as 
E0217. 
 
You asked the Plan to pre-approve the water circulating heating pad. You say that you feel this should be 
covered since your doctor wrote a prescription for it to help with your healing after knee surgery. The Plan 
denied your request. The Plan says Medicare does not provide coverage for the requested type of heating pad. 
 
The Plan must follow Medicare rules. Medicare rules say that while standard electric heating pads may be 
covered, water circulating pads with a pump are not shown to be reasonable and necessary and will be denied. 
Therefore, we decided that the Plan does not have to pre-approve a water circulating heating pad with pump 
coded as E0217.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on June 16, 
2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you should not owe a 
copayment for routine eye care. The Plan denied your request. The Plan says the claim was 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 $35 
copayment for specialist services. 
 
You received services from an ophthalmologist on June 16, 2020. An Ophthalmologist is considered a 
specialist. Furthermore, the claims were billed with diagnostic codes showing that services went beyond 
routine eye care. Therefore, you are responsible to pay the $35 copayment.   
 
You have been asked to pay a $35 copayment for specialist services. Specialist services fall within the 
physician/practitioner services, including doctor?s office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist services provided on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pressure-reducing mattress. 
 
You asked the Plan to pre-approve the requested mattress. You say that the enrollee has a non-healing wound 
site, and back discomfort. The Plan denied your request. The Plan says the enrollee does not have a condition 
that is indicated for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that pressure reducing support surfaces are only covered 
under certain medical indications.  
 
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 requested mattress. Our physician 
reviewer found that the enrollee has a chronic open surgical site on her left lateral ankle, with fat exposed. The 
enrollee also has chronic lower back pain, and bilateral osteoarthritis of the hips. The documentation does not 
support that the enrollee has large or multiple stage II, III, or IV pressure ulcers, of a myocutaneous flap, or 
skin graft on the trunk or pelvis. When the stated coverage criteria are not met, the requested item is not 
reasonable and 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 requested mattress have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pressure-reducing mattress.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 10, 2020. 
 
You asked the Plan to pay for the lab services. 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 requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 13, 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 screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on May 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 22, 2019. 
 
You asked the Plan to pay for . The Plan denied your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on October 22, 2019.