Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 31 2018. 
 
You asked the Plan to pay for the services provided. You say that the original claim was submitted prior to the 
timely filing deadline. The Plan denied your request. The Plan says the claim was received past the allowed 
timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services provided was not filed until August 18, 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 medical services provided on May 31 2018.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 25, 2020, to 
September 28, 2020. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says that the 
enrollee's care could have been provided at a lower level, such as observation. 
 
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.  
 
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 services. Our physician 
reviewer found that the enrollee presented to the emergency room for the evaluation of an allergic reaction after 
the fistula gram with angioedema, urticaria, lethargy, and heaviness of the tongue. She was evaluated and 
admitted as an inpatient. Her condition stabilized and improved and then was discharged to home. The review 
has determined that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier 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 the inpatient services have been met. Therefore, we decided that the Plan has to 
pay for the acute inpatient hospital care provided from September 25, 2020, to September 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasounds provided on March 18, 
2020. 
 
You asked the Plan to waive the copayment for the ultrasounds. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the pelvic ultrasound (CPT Code 76856) and transvaginal ultrasound 
(76830) provided on March 18, 2020. You are asked to pay a $100 copayment for the ultrasounds. Your EOC 
states that enrollees must pay a $100 copay for all other diagnostic tests. 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 ultrasounds provided on March 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on 
July 3, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the surgery was needed but you 
were not aware of the insurance issues. The Plan denied your request. The Plan says the coinsurance was 
applied 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 50% 
coinsurance for out-of-network surgery services at an outpatient hospital.  
 
Review of the file shows that you received outpatient surgical services on July 3, 2020. You have been asked to 
pay a 50% coinsurance for these services. These services fall within the out-of-network surgery services at an 
outpatient hospital 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 outpatient 
hospital services rendered on July 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on July 29, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you never paid this before. 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 allowed amount is 
$1,863.53. The total amount you are being asked to pay is $372.71 ($1,863.53 x 20% = $372.71). 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 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services with dental codes D2960 and D9630 
provided on September 16, 2020. 
 
You asked the Plan to pay for dental codes D2960 and D9630. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D2960 and 
D9630 are not covered under your supplemental dental benefit. 
 
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, dental codes D2960 and D9630 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services with dental codes D2960 and D9630 provided on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle. 
 
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 vehicle. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found you are able to 
participate effectively in MRADLs in the home. Your mobility deficit is currently helped by a walker. 
 
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 vehicle have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 1 heavy duty power operated vehicle.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the electrocardiogram (93010) provided on June 29, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that CMS does not separately pay any provider 
or supplier other than the facility for services furnished to the beneficiary for surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that A/B MACs (B) must pay for the PC of radiology services furnished by a physician to an 
individual patient in all settings under the fee schedule for physician services regardless of the specialty of the 
physician who performs the service. 
 
We find that CPT code 93010 is supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 93010 has a Pro/Tech Flag of 2. This indicator identifies stand-alone codes that describe the physician 
work portion of selected diagnostic tests for which there is an associated code that describes the technical 
component of the diagnostic test only and another associated code that describes the global test. Based on this 
information, we decided that Medicare rules for coverage of the electrocardiogram have been met. Therefore, 
we decided that the Plan has to pay for the electrocardiogram (93010) provided on June 29, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to provide injection, romosozumab-aqqg (J3111). 
 
You asked the Plan to provide injection, romosozumab-aqqg (J3111). You say that the enrollee's medical 
condition impacts the enrollee's quality of life. The Plan denied your request. The Plan says this drug is not 
approved for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 provide injection, romosozumab-aqqg (J3111). Our 
reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found the drug is 
not FDA approved for the requested use. The drug is not supported in any of the CMS compendia for the 
requested use. This reviewer did not find any supportive citations in a PubMed search. The use is not listed as 
not indicated, not recommended or not supported in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection, romosozumab-aqqg (J3111) have not been met. Therefore, we 
decided that the Plan does not have to provide injection, romosozumab-aqqg (J3111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the periodontal maintenance. You say that you need this medically 
necessary treatment. The Plan denied your request. The Plan says this is not a covered service. 
 
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 pre-approve the 
periodontal maintenance (D4910).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp for the enrollee. 
 
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee's blood counts are within normal limits. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Aranesp. Our reviewer says that 
Aranesp is not medically reasonable and necessary. Aranesp is not FDA indicated for chronic kidney disease 
and chemotherapy induced anemia without a hemoglobin less than 10. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for Aranesp. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not 
require transfer to LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an ACH for COVID-19 and 
progressive renal failure. The enrollee is not intubated/ventilated. There is no evidence that the enrollee 
requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level 
of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current 
ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower 
level of care for any ongoing long term care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 13, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is out-of-network, the services were not referred by a network 
provider or rendered in a participating facility, and the services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on May 13, 2020, 
by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on September 26, 2020 that 
applied to the deductible. 
 
You asked the Plan to pay for this cost share. You say that you do not believe these charges are correct. The 
Plan denied your request. The Plan says in 2019, you had a different Medicare Advantage Plan called a Private 
Fee-for-Service Plan which did not have a deductible to meet. The Plan says that at the time this claim 
processed, you had not met the deductible for 2020.  
 
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 was a $300 deductible for 2020. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $300 deductible. This cost sharing is a contractual obligation that 
had not been met at the time of service. Therefore, we decided that the Plan does not have to pay for a 
physician visit provided on September 26, 2020 that applied to the deductible.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to reduce the cost share for the duplex scan (93971) provided on August 4, 2020. 
 
You asked the Plan to reduce the cost share for the duplex scan. You say that  The Plan denied your request. 
The Plan says that you received an ultrasound on the date of service at issue in this appeal. The Plan says that 
the correct copayment has applied per your contract with the Plan. 
 
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 $5 
copayment for vascular studies. Your contract says you will only pay one copayment per day even if multiple 
tests are performed. You can find this information on pages 71-72 of the Plan's 2020 Evidence of Coverage. 
Therefore, we decided that the Plan has to reduce the cost share for the duplex scan (93971) provided on 
August 4, 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 waive the $774.60 coinsurance charged for genetic testing provided 
on August 12, 2020. 
 
You asked the Plan to waive this coinsurance. You say that you do not agree with the cost share charged for 
this testing. The Plan denied your request. The Plan says the Medicare allowed payment to the provider for this 
service is $3873.00. The Plan says that 20% of $3873.00 is $774.60, which is your cost share as the Plan pays 
80% or the balance which is $30798.40 to the provider.  
 
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 genetic testing. 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 $774.60 coinsurance charged for genetic testing provided 
on August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (E0673 and E0675) provided 
on August 4, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient.  
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment (E0673 and E0675) provided on 
August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitored anesthesia care rendered on September 25, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that any diagnosis code not listed does not support 
medical necessity for code 01992. 
 
We looked at the file and Medicare rules. The provider submitted a claim for code 01992 with diagnosis code 
M54.16. This diagnosis code is not listed as one that supports medical necessity for this procedure code. 
Therefore, we decided that the Plan does not have to pay for the monitored anesthesia care rendered on 
September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 13, 2019. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until August 18, 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 medical services provided on August 13, 2019.