Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pelvic support device. 
 
You asked the Plan to pre-approve the pelvic support device. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not 
medically necessary. 
 
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 pelvic support device. Our 
physician reviewer found the health plan should cover the cost of a pessary. However, our physician reviewer 
agrees with the health plan that if they are asking for an electrical pelvic floor stimulator then you do not meet 
the criteria for that because you have no incontinence symptoms.. 
 
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 pelvic support device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the pelvic support device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 2, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for observation services provided from 
February 9, 2020 to February 10, 2020. 
 
You asked the Plan to waive the deductible for observation services. You say that you disagree with the 
charges because you had a seizure in the emergency room and had no control over who treated you. 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. Your 
contract with the Plan says that there is a $500 deductible for out-of-network outpatient hospital observation.  
 
You received observation services from an out-of-network charges from February 9, 2020 to February 10, 
2020. The record shows that you had paid $145.35 toward the $500 deductible prior to receiving the services. 
Therefore, you are responsible to pay the total allowed amount of $174.73.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
hospital observation. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$500 deductible for out-of-network outpatient hospital observation. This cost sharing is a contractual obligation 
that had not been met at the time observation services was received on February 9, 2020 to February 10, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for observation services provided 
from February 9, 2020 to February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 15, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on November 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compounded bupivacaine and sufentanil provided for use 
in an implanted infusion pump billed with two units of code J3490. 
 
You asked the Plan to pay for the compounded drugs as billed. You say that this is medically necessary and 
should be paid. The Plan denied your request. The Plan says these drugs were not correctly billed according to 
Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that compounded drugs for use in an infusion pump 
must be billed using one unit of J7999-KD with the name and dosage of each drug in the refill reported in Box 
19 or the electronic equivalent.  
 
In this case, two line items of J3490 were used to bill these drugs. This is not correct based on the Medicare 
rules for billing of compounded drugs. Therefore, we decided that the Plan does not have to pay for the 
compounded bupivacaine and sufentanil provided for use in an implanted infusion pump billed with two units 
of code J3490.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living services provided on January 20, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for assisted living 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 assisted living services provided on January 20, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray and endodontic therapy provided on April 28, 2020.
You asked the Plan to pay for the limited oral evaluation, intraoral x-ray and endodontic therapy. You say that the in-network dentist wouldn't take you, so you were forced to go out-of-network. The Plan denied your request. The Plan says payment cannot be issued for services 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 pay for the limited oral evaluation, intraoral x-ray and endodontic therapy provided on April 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from November 27, 
2019 to December 6, 2019. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says the 
self-administered drugs are not a benefit under your 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 pay for the self-administered drugs 
provided from November 27, 2019 to December 6, 2019.  
 
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from March 
10, 2019 at 11:16am through March 11, 2019. 
 
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our physician 
reviewer found the review indicates that by 11:15 a.m. on March 10, 2019, the enrollee was stable for safe 
transport to a Plan facility because the enrollee's a-fib was identified, and the enrollee was started emergently 
on intravenous (IV) Cardizem. The enrollee was started on Lovenox for possible pulmonary embolism and IV 
antibiotics for sepsis. There was no documentation of cardiopulmonary deconditioning occurring overnight and 
the enrollee was deemed stable for transfer during the History and Physical exam on March 9, 2019. The 
enrollee's a-fib converted to normal sinus rhythm and the enrollee was taken off IV Cardizem and started on 
pill form and cleared for transfer by Cardiology. The review indicates that the post-stabilization care services at 
the non-participating facility March 10, 2019 at 11:16am to March 11, 2019 were not medically necessary or 
reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the 
patient was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care provided to the enrollee from March 10, 2019 at 11:16am 
through March 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided on October 12, 2018by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab tests. You say that these services were referred by an in-network provider. 
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 lab tests provided on October 12, 2018by an out of 
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided by a participating provider on March 18, 2020.
You asked the Plan to waive the copayment for physician services. You say that you paid for the surgery. You say that these services should have been included in that 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 $50 copayment for physician/practitioner services/specialist services. You have been asked to pay a $50 copayment for physician services. The correct copayment has been applied to the services provided. Physician services falls within the physician/practitioner services/specialist services 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 physician services provided by a participating provider on March 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
February 22, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to 
pay this because you were transferred for insurance reasons. The Plan denied your request. The Plan says that 
you were charged 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 $150 
copayment per ambulance trip, each way.  
 
You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls 
within the ambulance trip, each way 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 ambulance transport provided on February 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851) suspension sleeve (L2397) and 
neuromuscular stimulator, electronic shock unit (E0745) provided February 26, 2020. 
 
You asked the Plan to pay for the orthoses and electric shock unit. You say that please see the attached 
documentation to prove medical necessity. The Plan denied your request. The Plan says the enrollee is not 
eligible for telehealth services, there is no actual physical exam, and all information was provided over the 
phone. 
 
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 knee orthosis (L1851) 
suspension sleeve (L2397) and neuromuscular stimulator, electronic shock unit (E0745) provided February 26, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lift chair purchased on November 20, 2019 through 
December 13, 2019 from non-participating retailer. 
 
You asked the Plan to pay for lift chair. You say that you are requesting reimbursement of services rendered. 
The Plan denied your request. The Plan says a provider must be eligible to participate in Medicare to receive 
payment. The Plan states except for emergency services, the plan cannot pay a provider who is not eligible to 
participate in Medicare. The plan has confirmed that the provider is not 
eligible for Medicare. 
 
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. 
 
Review of the file shows that you purchased a lift chair on November 20, 2019 from a provider that is not 
certified with Medicare. The Medicare rules say that to receive payment for covered Medicare items or services 
from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned 
claim), a provider or supplier must be enrolled in the Medicare program. 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 lift chair purchased on November 20, 2019 through December 13, 2019 from non-
participating retailer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 29, 
2020 through March 3, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review indicates that the enrollee's blood pressures stabilized by February 28, 
2020. The enrollee appeared to be appropriate for discharge from the acute medical setting after February 28, 
2020. As of February 28, 2020 the enrollee did not require inpatient level of care services. The enrollee did not 
require any inpatient diagnostic studies or therapeutic interventions. The enrollee was discharged on March 3, 
2020. The review has determined that inpatient stay from February 29, 2020 through March 3, 2020 was not 
medically necessary or reasonable. The enrollee's care could have been appropriately provided at a less intense 
level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 29, 2020 through March 
3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a mammogram (77066) and a digital breast tomosynthesis (G0279) provided April 15, 2020.
You asked the Plan to waive the copayments for the mammogram and tomosynthesis. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were 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 copayment for outpatient diagnostic tests. You have been asked to pay a $40 copayment for two outpatient diagnostic tests, a mammogram and tomosynthesis. Each test has a $20 copayment per the Evidence of Coverage. 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 a mammogram (77066) and a digital breast tomosynthesis (G0279) provided April 15, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided February 18, 2020 to February 26, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you did not want to stay at the 
facility extra days and the copayment should be waived. The Plan denied your request. The Plan says the 
correct copayment was applied for days you received services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
per day copayment for Days 21-31 of a SNF stay.  
 
You have been asked to pay a $1,200 copayment for 8 days of SNF care ($150 per day). 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 skilled nursing facility (SNF) services provided February 18, 2020 to 
February 26, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by an opted-out physician on 
December 4, 2019. 
 
You asked the Plan to pay for office visit. You say that you were referred to this provider and see no reason for 
the Plan to reject payment. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because this provider has opted-out of Medicare and is not eligible for payment. 
 
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 pay for 
an office visit provided by an opted-out physician on December 4, 2019.