Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network (OON) provider.

You asked the Plan to pay for infusion service. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 had network providers available who could have provided 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 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections of ferric carboxymaltose (a 
Medicare Part B prescription drug) provided on October 28, 2020 and November 4, 2020. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you feel that this is too costly. The 
Plan denied your request. The Plan says the coinsurance 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 Part B drugs. The allowed amounts of these drugs total $1,228.50, resulting in a total 
coinsurance responsibility of $245.70. 
 
You have been asked to pay 20% coinsurance for Part B drugs. Part B drugs fall 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 injections of ferric 
carboxymaltose (a Medicare Part B prescription drug) provided on October 28, 2020 and November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walk-in whirlpool tub (K1003) purchased on June 26, 
2020. 
 
You asked the Plan to pay for a walk-in whirlpool tub. You say that you need this item to be able to bathe at 
home as you can no longer lift your legs to get into the tub. The Plan denied your request. The Plan says rules 
for payment have not been met. 
 
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 a walk-in whirlpool tub (K1003) purchased on June 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
provided on October 28, 2020. 
 
You asked the Plan to waive the copayment for EGD. You say that you had this procedure at a facility that was 
not a hospital. The Plan denied your request. The Plan says the copayment amount you are being charged is 
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 $350 
copayment for EGD at an outpatient hospital facility. This service was performed by an outpatient hospital 
facility, so the outpatient hospital surgery copayment applies to this claim. 
 
You have been asked to pay $350 copayment for EGD. EGD falls within the Outpatient Surgery, Including 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) provided on 
October 28, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for CT of the Pelvis (72192).

You asked the Plan to pay for the CT of the Pelvis. You say that you would like reconsideration because this service denied as a duplicate in error. The Plan denied your request. The Plan says that CPT code 72192 is a column II code to CPT code 74176 which was billed on the same date of service.

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 72192 is supported in the record. Specifically, the record shows that CPT code 72192 and 74176 were rendered by separate providers. NCCI edits apply to line items for the same NPI. Based on this information, we decided that Medicare rules for coverage of the CT of the Pelvis have been met. Therefore, we decided that the Plan has to pay for CT of the Pelvis (72192).

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 tetanus injection.

You asked the Plan to pay for the tetanus injection. You say that the shot should have been a booster or preventative service. The Plan denied your request. The Plan says the injection falls under your deductible.

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 you have a $230 deductible.

The item or service you asked the Plan to pay for falls under your deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $230 deductible before the Plan will pay their share for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time the tetanus injection. Therefore, we decided that the Plan does not have to pay for the tetanus injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the second opinion from an out-of-network provider.. You say that you 
would like reconsideration because this provider was recommended to you and you would like to be treated as 
soon as possible. The Plan denied your request. The Plan says the services are not emergent or urgent and are 
available within your tertiary network. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the deductible for laboratory testing provided on November 13, 2020. 
 
You asked the Plan to waive the deductible for lab tests. You say that this lab work should be included in your 
annual wellness visit. The Plan denied your request. The Plan says that the deductible amount you are being 
charged is correct. 
 
The Plan must follow Medicare rules. 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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
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 submitted the incorrect Evidence of Coverage (EOC) for the health 
plan you were enrolled in on this date of service. The Plan did submit an excerpt of the correct EOC, but this 
excerpt did not adequately describe the deductible benefit or any other cost-sharing benefits under your health 
plan. Without this information, we cannot determine whether the deductible amount you are being charged is 
correct or that any other cost-sharing amount could be applied to this claim. Therefore, the Plan has not shown 
that its decision to hold you responsible for $60.93 deductible is correct according to the Plan contract and 
Medicare rules. Therefore, we decided that the Plan has to waive the deductible for laboratory testing provided 
on November 13, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to pay for the
laboratory services. The Plan denied your request. The Plan says services rendered by non-participating
providers require prior authorization which 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 had network providers
available who could have provided 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 laboratory services provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has prostate cancer 
diagnosed in 2012 with history of low prostate specific antigen (PSA) and a negative PET scan. He has not 
tried and failed the Plan's required drugs, one oral bisphosphonate and zoledronic acid. The records do not 
show that the required drugs would be contraindicated or less effective; therefore, the services are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve 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. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.  
 
Benefits for these services 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cystoscopy with removal of stone and stent (52310).

You asked the Plan to reduce the copayment for the stent removal procedure. You say that the removal procedure was brief and did not include anesthesia or sedation. You were able to remove the previous, smaller stent on your own in just as little time. You feel that the surgical copayment that was applied is too great for the service provided and feel an office visit copayment is more appropriate. The Plan denied your request. The Plan says this service is classified as a surgical procedure. Outpatient surgery has a $250 copayment.

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 outpatient surgery and other medical services.

You have been asked to pay a $250 copayment for the stent removal procedure. The stent removal procedure falls within the outpatient surgery and other medical 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 reduce the copayment for the cystoscopy with removal of stone and stent (52310).

Your complaint about the high copayments for certain procedures and services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
for the enrollee. 
 
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your 
request. The Plan says that prior authorization criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not requires 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit provided by an out of network provider.

You asked the Plan to pay for the outpatient visit. You say that you would like the Plan to reconsider the denial. The Plan denied your request. The Plan says you did not request prior authorization for the non-urgent 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 the outpatient visit provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Shingrix (Shingles) vaccination provided on June 22, 2020. 
 
You asked the Plan to pay for vaccination. You say that you are requesting reimbursement for this. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this is not covered 
by Medicare Part B. The Plan also says that they have issued reimbursement to you under your Medicare Part 
D benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccination. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to vaccination. 
Therefore, we decided that the Plan does not have to pay for a Shingrix (Shingles) vaccination provided on 
June 22, 2020.  
 
Benefits for vaccination 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for hepatobiliary system imaging (78226).

You asked the Plan to pay for the hepatobiliary system imaging. You say that you would like reconsideration because this procedure is not specific to a place of service. The Plan denied your request. The Plan says this claim was willed with an outpatient place of service code, but the member was inpatient on this date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 78226 is not supported in the record. Specifically, this claim was billed with an outpatient place of service code. The record indicates that this member was registered inpatient on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the hepatobiliary system imaging have not been met. Therefore, we decided that the Plan does not have to pay for hepatobiliary system imaging (78226).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided January 5, 2020 to January 
10, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that DRG 871 was correctly billed. The Plan 
denied your request. The Plan says DRG 193 is more appropriate for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG. DRG 871 is defined as Septicemia 
or Severe Sepsis with Major complications or comorbidities.  
 
In this case, you billed the services provided January 5, 2020 to January 10, 2020 with DRG 871. 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 inpatient hospital care. Our reviewer says that DRG 871 
is not supported. Our physician reviewer found the records support removing diagnosis code A41.9 and 
R65.20. This revision results in a change from DRG 871 to DRG 193.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate DRG 871. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital care provided January 5, 2020 to January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided by a chiropractor from January 3, 
2020, to October 14, 2020. 
 
You asked the Plan to pay for office visits. You say that you still needed treatment to correct subluxation, so 
you do not understand why these visits were denied. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because this provider is out-of-network with the Plan and these services 
are not covered when performed by a chiropractor. 
 
The Plan must follow Medicare rules. 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 rules say 
that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 office visits provided by a chiropractor from 
January 3, 2020, to October 14, 2020.