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

 
We decided that the Plan does not have to pay for the selective catheter placement, 3D rendering with 
interpretation and reporting, moderate sedation services, catheter, closure device, guide wire, introducer/sheath, 
injections, Diphenhydramine hydrochloride, and low osmolar contrast material provided on January 24, 2020 
by an OON provider. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed with a 
retro-authorization request. The Plan denied your request. The Plan says the services were rendered by a 
provider who is not under contract with the health plan. 
 
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 selective catheter placement, 3D rendering 
with interpretation and reporting, moderate sedation services, catheter, closure device, guide wire, 
introducer/sheath, injections, Diphenhydramine hydrochloride, and low osmolar contrast material provided on 
January 24, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide Group 3 power wheelchair upgraded electronics and Recline 
Body Fit System. 
 
You asked the Plan to provide the power wheelchair Electronic connection (E2311), Expandable controller 
harness (E2313), Expandable controller (E2377), and Recline Body Fit System (K0108). You say that the 
enrollee needs the upgraded electronics and Recline Body Fit System. The Plan denied your request. The Plan 
says the upgraded electronics are not medically necessary and the Recline Body Fit System cannot be 
unbundled from the included power seating system. 
 
The Plan follows Medicare rules. Medicare rules say that that options and accessories for wheelchairs are 
covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory 
itself is medically necessary.    
 
Documentation shows that the enrollee has normal range of motion and 5/5 strength in the bilateral upper 
limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power 
options using their own switches which are included in the allowance of these power options. The Recline 
Body Fit System cannot be billed separately. Therefore, we decided that the Plan does not have to provide a 
Group 3 power wheelchair upgraded electronics and separate Recline Body Fit System.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs the services that are provided 
at a SNF. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria because 
the enrollee does not require the daily skilled services required to qualify for a skilled nursing facility stay. 
 
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 
the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does 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. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. 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 
SNF services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz (J7321).You asked the Plan to pre-approveSupartz. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Supartz. Our reviewer says that Supartz is not medically reasonable and necessary for the enrollee. Our physician reviewer found there is no documentation of trial and failure of Monovisc or Orthovisc. Our reviewer also found that recent literature shows visco injection does not work. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz (J7321).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided on January 6, 2020. 
 
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that setup 
and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says 
payment for this service is included in the facility payment. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made with outside providers. This service was provided via 
arrangement of the facility. Payment for this service would have been included under the facility claim. 
Payment to you for this service is the responsibility of the facility. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the perfusionist services provided on January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Xolair injection you received on July 
8, 2020. 
 
You asked the Plan to waive the coinsurance for the Xolair injection. You say that you cannot afford the cost of 
this drug. The Plan denied your request. The Plan says you were charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Xolair injection. The Xolair injection falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Xolair 
injection you received on July 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you 
received on June 11, 2020, and June 15, 2020. 
 
You asked the Plan to waive the copayments for the PT services. You say that you got COVID-19 and you feel 
you shouldn't have to pay any copayments because they were related to this. The Plan denied your request. The 
Plan says you were charged these copayments 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 $15 
copayment per visit for Medicare-covered therapy services.  
 
You have been asked to pay a $15 copayment per visit for the PT services. These copayments apply regardless 
of the reason for the PT services. 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 physical therapy (PT) 
services you received on June 11, 2020, and June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig rendered on January 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 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. 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 pay for the wig rendered on January 5, 2020.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

You asked the Plan to waive the copayment for and pay for inpatient hospital care. You say that you have a 
Plan that covers hospitalization so you want to be reimbursed for the difference for a private room since the 
Plan pays for a semi-private room. The Plan says that the copayment amount you are being charged is correct, 
and the denial of payment for additional private room charges is correct because these charges are not covered.  
 
We decided that the Plan has to waive the copayment for inpatient hospital care provided from May 5, 
2020, to May 11, 2020. 
 
The Plan must follow Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms 
all cost sharing information. 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. 
 
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 provide a copy of the applicable 2020 Evidence of Coverage 
for the plan that you were enrolled in at the time of service. Without this document, we cannot determine 
whether the cost-sharing amount you have been asked to pay is correct according to the Plan contract. 
Therefore, the Plan has not shown that its decision to apply a $40 copayment to this claim is correct or 
justified. Therefore, we decided that the Plan has to waive the copayment for inpatient hospital care.  
 
We also decided that the Plan does not have to pay for an additional private room charge. 
 
The Plan follows Medicare rules. Medicare rules say that if an enrollee requests private room accommodation, 
the enrollee accepts the liability for these charges and the hospital provider will bill the enrollee directly. 
Therefore, we decided that the Plan does not have to pay for additional private room charges. 
 
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 home visit for the evaluation and management of an 
established patient provided on May 28, 2020 by an OON provider. 
 
You asked the Plan to pay for the home visit. You say that due to COVID-19 restrictions, authorizations should 
not be needed under telemedicine. The Plan denied your request. The Plan says the service was rendered by a 
non-network provider. The Plan also says that the services were not urgent or emergent, and were not 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 
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 home visit for the evaluation and management 
of an established patient provided on May 28, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device (93297) provided on April 6, 2020. 
 
You asked the Plan to pay for the interrogation device. You say that you would like reconsideration because 
this service is billed on a quarterly basis. The Plan denied your request. The Plan says ode 93297 is a 
component of the column I codes 93296 and 93295 and only codes 93296 and 93295 will be reimbursed as no 
modifiers are allowed to unbundle these services. 
 
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, we have confirmed that code the 
interrogation device has a bundled relationship with codes 93295 and 93296 and cannot be paid as billed. This 
code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the interrogation device (93297) 
provided on April 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on June 11, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you already paid the $40 copayment 
and disagree with the additional 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 $250 
copayment for diagnostic radiology.  
 
You have been asked to pay a $250 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a CT scan provided on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the negative pressure wound therapy electrical pump 
provided on September 21, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the negative pressure wound therapy electrical pump. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the item rendered is not a 
covered benefit. 
 
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 negative pressure wound therapy electrical 
pump provided on September 21, 2019 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 medical services provided on May 15, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the physician certification for Medicare-covered home health services under a 
home health plan of care. You say that you would like a retro authorization. The Plan denied your request. The 
Plan says the services were rendered by a non-participating provider. The Plan also says that prior authorization 
was not obtained. 
 
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 May 15, 2020 by 
an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from June 17, 2020, to June 30, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you got COVID-19 
and you feel that all of your medical bills should be covered in full. The Plan denied your request. The Plan 
says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per admission for inpatient hospital care.  
 
You have been asked to pay a $250 copayment per admission for the inpatient hospital services. This 
copayment applies regardless of the reason for the admission. 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 services you received from June 17, 2020, to June 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stretcher van transportation services provided on 
December 5, 2019. 
 
You asked the Plan to pay for the stretcher van transportation services. You say that your doctor ordered this 
service. 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 stretcher van transport 
services.  
 
The services you have asked the Plan to pay for are stretcher van transport services. Therefore, we decided that 
the Plan does not have to pay for the stretcher van transportation services provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided March 
16, 2020 to March 18, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF 
services provided. The Plan denied your request. The Plan says the SNF benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from November 7, 2019 - 
March 15, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided March 16, 2020 to March 18, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you were advised by a Plan representative that the 
Plan covered 80% of the cost of orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.  
 
Your complaint regarding receiving inaccurate information about the coverage for these orthotics is considered 
to be a grievance. We do not have the jurisdiction to address grievances. Please contact the Plan for more 
information about your grievance.