Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from December 23, 2019 
through December 24, 2019. 
 
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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found it was certainly medically reasonable to feel that stay would be more than two midnights in a 
patient on intravenous (IV) narcotics, IV antibiotics, and requiring acute surgical intervention. The admission 
criteria was met and was medically reasonable. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from December 23, 2019 through December 24, 2019.  
 
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: 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 documentation supporting that the member requires services 
that cannot be provided at the current inpatient rehabilitation facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tetanus and diphtheria toxoids vaccine (90714) provided on 
September 3, 2019. 
 
You asked the Plan to pay for the vaccine. You say that you would like reconsideration because you received 
the immunizations from your primary physician and they are a covered benefit. The Plan denied your request. 
The Plan says immunizations are not covered unless they are directly related to the treatment of an injury or 
direct exposure to a disease or condition. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for a tetanus and diphtheria toxoids vaccine (90714) 
provided on September 3, 2019.  
 
Benefits for the vaccine 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
surgery services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive eye exam (92004) and eye refraction (92015) 
provided January 29, 2020. 
 
You asked the Plan to pay for the vision services. You say that when you arrived at the eye clinic you were 
assured by the staff that your new plan would cover the services. The Plan denied your request. The Plan says 
the routine vision exam and refraction services are not covered when provided out of network. 
 
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. The Plan covers these services when rendered by an in-network provider. 
 
We looked at the file and the Plan's rules. Routine eye exams and refraction services are not covered when 
rendered by an out-of-network provider. Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive eye exam (92004) and eye refraction (92015) provided January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on January 8, 2020. 
 
You asked the Plan to pay for office visit. You say that you were seen in this office for the first time. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this service is not 
covered by Medicare or the Plan when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided by a chiropractor on January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a suction suspension (CPT L5652) billed for date of service 
December 5, 2019. 
 
You asked the Plan to pay for the suction suspension. You say that the suction valve is absolutely medically 
necessary to help hold the enrollee's leg on. The Plan denied your request. The Plan says the billed service in 
dispute was not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supply in dispute. The records provided included a 
supply order for CPT codes L5695, L5673, and L5694. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for a suction suspension (CPT L5652) billed for date of service December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and resin-based 
composite provided on February 25, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and resin-based composite. You say 
that you were not aware that your dental provider was not in-network and you would not be reimbursed. The 
Plan denied your request. The Plan says these services were rendered by a provider who has opted out of 
Medicare. The Plan also says that services from Medicare opt out providers are not covered under your plan.  
 
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 periodic oral evaluation, prophylaxis, and resin-based composite provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions provided on January 23, 2020. 
 
You asked the Plan to pay for the extractions. You say that the coverage states you can see any licensed dentist 
and receive 50% coverage up to $1,000. The Plan denied your request. The Plan says payment cannot be issued 
for services performed by a provider that 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 extractions provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heel stabilizer (L3170), a shoulder-hand-wrist orthosis 
(L3960), and a wrist-hand orthosis (L3916) provided to the enrollee on February 21, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
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 a heel stabilizer (L3170), a 
shoulder-hand-wrist orthosis (L3960), and a wrist-hand orthosis (L3916) provided to the enrollee on February 
21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection of ondansetron HCl, Lutetium-
177 (a therapeutic radioactive material), and radiopharmaceutical therapy provided on February 19, 2020. 
 
You asked the Plan to waive the copayment for Part B drugs and nuclear medicine procedure. You say that this 
visit should only have a $250 copayment. The Plan denied your request. The Plan says the coinsurance and 
copayment amounts you are being charged are correct. 
 
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 drugs and $350 copayment for nuclear medicine at an outpatient hospital. At the time this 
claim was processed, $55 of the $4,900 in-network maximum out-of-pocket amount had been met. The allowed 
amounts of the drugs total $39,777.07, resulting in a coinsurance amount of $4,495 because this amount, along 
with the $350 copayment you have been asked to pay, meets the $4,900 in-network maximum out-of-pocket 
amount for 2020. Your total cost-sharing obligation is therefore $4,845. 
 
 
 
 
You have been asked to pay 20% coinsurance for drugs and $350 copayment for nuclear medicine procedure, 
up to an in-network maximum out-of-pocket amount of $4,900. Part B drugs and nuclear medicine procedure 
fall within the "Medicare Part B Prescription Drugs" and "Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies" benefit categories. 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 injection 
of ondansetron HCl, Lutetium-177 (a therapeutic radioactive material), and radiopharmaceutical therapy 
provided on February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 11, 2020 
through January 14, 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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found both of the above presentations meet criteria for admission, with a lesion responsible for blood 
loss and need for transfusion combined with a common duct stone that needs to be addressed prior to 
discharging patient home. The admitting physician reasonably expected that the patient's necessary hospital 
care (including earlier emergency department (ED) and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 11, 2020 through January 14, 2020.  
 
 
 
 
 
 
 
 
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: Favorable

 
We decided that the Plan has to pre-approve continued EpiFix bioengineered skin substitute (BSS) 
applications. 
 
You asked the Plan to pre-approve the continued use of EpiFix. You say that this is medically necessary 
treatment for the non-healing wound. The Plan denied your request. The Plan says that this product is not for 
use for more than 12 weeks. No further applications can be allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 continued use of EpiFix. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a full-thickness open surgical wound of the right lower leg. On 
8/5/20, it is documented that the enrollee's RLE wound was improving. It has been demonstrated that 
application of dehydrated human amnion/chorion membrane allograft is an effective therapy to heal chronic 
wounds, and has significant benefit compared with standard therapies. Continued application would reasonably 
be expected to provide additional benefit in this case.  
 
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 continued use of EpiFix have been met. Therefore, we decided that the Plan 
has to pre-approve continued EpiFix bioengineered skin substitute (BSS) applications.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services described by CPT codes 67840-E1-51-
79, two units of 11442-SX-51-79, and code the ocular photography services coded with 922885. 
 
You asked the Plan to pay for the medical services as billed. You say that the enrollee had excisions of two 
lesions on the face, two on the eyelid, and two on the scalp. This was coded correctly and should be paid. The 
Plan denied your request. The Plan says no detailed operative note was provided to support the billed charges. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information to 
corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage 
criteria have been met. 
 
In this case, no detailed operative report was provided showing exactly what services were rendered. The 
document provided does show that ocular photography was provided but did not include an interpretation and 
report of the findings which is required by the code definition of this procedure. Therefore, we decided that the 
Plan does not have to pay for the surgical services described by CPT codes 67840-E1-51-79, two units of 
11442-SX-51-79, and code the ocular photography services coded with 922885.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcranial magnetic stimulation (TMS) provided on 
October 29, 2019. 
 
You asked the Plan to pay for TMS. You say that you were told that no authorization was required, and the 
enrollee meets the criteria for this procedure. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because records have not been submitted to determine if a physician's order 
was given, how the enrollee came to the provider, or whether the service was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due for a claim.  
 
We looked at the file and Medicare rules. No medical records were submitted to the Plan to support the service 
billed on this claim. The Plan requested this information, but it was not provided. Without this information, you 
have not submitted sufficient information to the Plan to justify payment of this claim as billed. Based on this 
information, we decided that Medicare rules for coverage of TMS have not been met. Therefore, we decided 
that the Plan does not have to pay for transcranial magnetic stimulation (TMS) provided on October 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you are appealing the charge for the 
ambulance services because you were not transported to a hospital. You say that on the date of service you 
were at a restaurant when you briefly passed out. The restaurant called for an ambulance and when the 
responders arrived, they checked your blood pressure. You stated that everything seemed okay and so you were 
not transported. You say that you do not feel like you should have to pay the entire cost of the service and you 
asked the Plan to reconsider paying for the services. 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 February 6, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140) provided on January 17, 2020. 
 
You asked the Plan to pay for the extraction. You say that you were assured that you have a $500 allowance 
per year, but you were told that someone did not activate the coverage. The Plan denied your request. The Plan 
says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction (D7140) provided on January 17, 2020.