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

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided to the enrollee.You asked the Plan to pay forthe SNF services. The Plan denied your request. The Plan says the enrollee has used over the 100 days of SNF level of care during the benefit period.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 gone60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period. 


The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on July 24, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you had this injection before and it 
wasn't this expensive. The Plan denied your request. The Plan says the correct coinsurance has been 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 of the allowed amount for an injection. The total allowed 
amount is $1,253.76. The total amount you are being asked to pay is $250.75 ($1,253.76 x 20% = $250.75). An 
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 an injection provided by a participating provider on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient assisted living visit (99327) provided on June 
27, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the new patient assisted living visit. 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 by the facility or the provider; therefore, payment has been correctly denied. 
 
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 new patient assisted living visit (99327) 
provided on June 27, 2019, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the dentures and extractions provided on March 
13, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you had to have your teeth removed 
due to infection. You say that you have diabetes. You say that a plan representative advised up to $500 would 
be paid for extractions. You say that you were not given names of any in  network dentists. The Plan denied 
your request. The Plan says payment cannot be made for service performed by a provider who has opted out of 
Medicare. 
 
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 program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to 
reimburse you for the dentures and extractions provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and X-ray of knee (99213, 73560) provided on June 23, 2020, by an out of network (OON) provider.You asked the Plan to pay forthe office visit and X-ray of knee. 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 by the facility or the provider; therefore, payment has been correctly denied.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 forthe office visit and X-ray of knee (99213, 73560) provided on June 23, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (L1833, L2397) provided. 
 
You asked the Plan to pay for the medical equipment. You say that the items were medically necessary. The 
Plan denied your request. The Plan says rules for telehealth services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for durable medical equipment 
(L1833, L2397)provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (scooter). 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says this will be used outside of the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found your mobility deficit 
does not impair participation in MRADLs in the home. Your mobility deficit can be helped by a manual 
wheelchair. The documentation reveals that your home does not have adequate space to safely maneuver the 
requested scooter. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (scooter).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug tests (G0480), specific gravity (84315) 
and creatinine blood (82565) provided on March 3, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for definitive drug tests, specific gravity and creatinine blood. You say that the 
services rendered were medically necessary. The Plan denied your request. The Plan says prior authorization 
must be obtained for non-emergent services rendered by an out-of-network provider. 
 
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 definitive drug tests (G0480), specific gravity 
(84315) and creatinine blood (82565) provided on March 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Gel-One injection (J7326) received on 
April 13, 2020. 
 
You asked the Plan to waive the coinsurance for a Gel-One injection. You say that you were never advised of 
the copayment. 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 20% 
coinsurance for chemotherapy drugs and all other drugs covered under Medicare Part B.  
 
You have been asked to pay $466.40 coinsurance, or 20% of the Plan-allowed amount of $2,332, for a Gel-One 
injection. A Gel-One 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 Gel-One injection (J7326) received on April 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429) provided May 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says an invalid diagnosis code was used on the claim. 
 
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 CPT code A0429 is not supported in the medical record. Specifically, I46.2 - Cardiac arrest due to 
underlying cardiac condition cannot be used as a primary diagnosis. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services (A0429) provided May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the eyewear purchased. 
 
You asked the Plan to reimburse for the eyewear. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says your plan does include some coverage for non-
Medicare-covered eyewear. The Plan says the EOC states that the plan will reimburse up to $75 for non-
Medicare-covered eyeglasses or contact lenses every calendar year, you have not yet requested to use this 
benefit this calendar year. The Plan states they did not yet apply this benefit to your eyewear claim because you 
specifically requested reimbursement under your cataract eyewear benefit. The Plan states that you still have 
until June 29, 2021, to file for reimbursement separately under this supplemental non-Medicare-covered 
eyewear benefit. 
 
 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
Your plan will cover one pair of eyeglasses after each cataract surgery that includes insertion of an intraocular 
lens. This coverage is a Medicare-benefit, and your EOC states in this same section that you will owe a 
copayment of $30 for Medicare-covered eyewear. Medicare?s coverage for eyewear is generally limited a basic 
pair of lenses and frames, which does not include coverage for added features like progressive lenses or UV 
protection. Medicare?s coverage is also limited to a set reimbursement rate. our EOC states on pages 73-74 that 
if you file for reimbursement of covered medical services that you already paid for out-of-pocket, the Plan will 
review your request and reimburse you for the Plan's share of the cost. In this case, the Medicare 
reimbursement rate for the eyeglasses was $182.69. After subtracting your $30 copayment, the final 
reimbursement amount was $152.69. Please note that your plan does include a separate $75 reimbursement 
each calendar year for non-Medicare-covered eyewear. The Plan's records show that you have not yet used this 
benefit in 2020. In your reimbursement request, you specifically requested reimbursement under your post-
cataract surgery eyewear benefit, so the Plan did not apply this benefit to the reimbursement. If you would like
 to apply your $75 reimbursement for non-Medicare-covered eyewear to your 
eyewear, you may file an additional request for reimbursement. Therefore, we 
decided that the Plan does not have to reimburse for the eyewear purchased.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is independent with mobility-related activities of daily living. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 20, 2019. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
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 genetic testing at issue in this appeal 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 genetic 
testing services provided on November 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation costs you incurred from April 14, 2020, to 
May 29, 2020. 
 
You asked the Plan to pay for the transportation costs. You say that the Plan should pay more for this. The Plan 
denied your request. The Plan says follow-up services are not covered. 
 
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 this benefit only covers 
TML expenses for you and one companion for the evaluation and transplant, not for follow-up or post-
operative visits or transplant related inpatient admissions after you receive your transplant. 
 
Review of the file shows that you incurred transportation costs for your transplant from April 14, 2020, to May 
29, 2020. The Plan has paid up to the benefit limit for these services. Follow-up and post-operative visits are 
not covered under this benefit. 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 pay for the transportation costs you incurred from 
April 14, 2020, to May 29, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says claims must be filed to the appropriate Medicare claims processing contractor no later 
than 12 months, or 1 calendar year, after the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services, 
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 February 14, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that it is difficult to shower without the shower 
stool because of shortness of breath and the low back pain. The Plan denied your request. The Plan says this 
item is not covered under Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Quattro 2.5 TENS/muscle stimulator. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that there is not supporting documentation for this device. 
 
The Plan must follow Medicare rules. Medicare rules say that a TENS is covered for the treatment of 
beneficiaries with chronic, intractable pain or acute post-operative pain.  
 
We looked at the file and Medicare rules. There is no documentation that this is being requested for treatment 
of the enrollee's pain. 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 pre-approve a Quattro 2.5 
TENS/muscle stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on July 21, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $325 
copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care/in-
network.  
 
You have been asked to pay a $325 copayment per day for an inpatient hospital stay. The total amount you are 
being asked to pay is $325. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 inpatient hospital stay provided by a 
participating provider on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight psychotropic test provided to the enrollee on 
May 20, 2020. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says the provider does not have a designated identification in PECOS as IM/neurology. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
case file does not contain documentation supporting that the enrollee in this case is suffering with refractory 
moderate to severe depression (based upon DSM-V criteria) after at least one prior neuropsychiatric medication 
failure. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the GeneSight psychotropic test provided to the enrollee on May 20, 2020.