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

 
We decided that the Plan does not have to waive the copayment for the echocardiography with CPT code 
93306 provided on August 31, 2020. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received an echocardiography 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 $160 
copayment for Outpatient diagnostic tests.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an 
echocardiography on August 31, 2020. You have been asked to pay a $160 copayment for the 
echocardiography. The echocardiography falls within the Outpatient diagnostic tests 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 echocardiography with CPT code 93306 provided on 
August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) 
therapy. 
 
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 TENS therapy for CLBP is covered for 
beneficiaries enrolled in a Medicare-approved clinical study. 
 
We looked at the file and Medicare rules. The file shows that the enrollee is not in a Medicare-approved 
clinical study for these services. 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 
transcutaneous electrical nerve stimulation (TENS) therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON physical therapy services. You say that you need services out-of-
network because you are staying with your ex-wife after surgery. The Plan denied your request. The Plan says 
these services are available in-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 physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement services provided on 
August 3, 2020. 
 
You asked the Plan to waive the copayment for the debridement services. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received debridement services, which are considered surgical services, 
in an outpatient hospital setting 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 $350 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received debridement 
services on August 3, 2020 provided in an outpatient hospital setting. You have been asked to pay a $350 
copayment for the debridement services. The debridement services fall within the Outpatient surgery 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 debridement services provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 11, 2019 and 
November 12, 2019 by an out of network provider. 
 
You asked the Plan to pay for nursing facility care. You say that it is not possible to request authorization 
before services are rendered. The Plan denied your request. The Plan says you did not request prior 
authorization as required. 
 
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 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 nursing facility care provided on November 11, 2019 and November 12, 2019 by 
an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 10, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 the laboratory services are not supported in the medical record. Specifically, if a laboratory assays 
two or more genes in an enrollee in parallel, then those two or more genes will be considered part of the same 
panel. These services billed are not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for acute inpatient hospital services. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that the services are 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 services are medically necessary. Our physician reviewer found the enrollee was brought to the 
emergency department on January 6, 2021 after being found wandering one mile from his home without a 
winter coat. He was unable to complete formal cognitive testing and could not understand the test instructions 
or respond appropriately. He was not oriented to the current year or month and was unable to state his reason 
for being at the hospital. The records support he lacked the capacity to make informed decisions regarding his 
health care matters. The records support a reasonable expectation that the enrollee will require at least two 
midnights of inpatient hospital care. 
 
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 acute inpatient hospital services.  
 
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 home infusion therapy services provided from March 20, 
2020, to March 27, 2020. 
 
You asked the Plan to pay for home infusion services. You say that the Plan has not made full payment of this 
claim. The Plan denied your request. The Plan says the denial of payment for these services is correct, because 
this code is not valid for Medicare purposes and is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S9500 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home infusion services have not been met. Therefore, we decided that the Plan does not have to 
pay for home infusion therapy services provided from March 20, 2020, to March 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye exam received on December 23, 2019. 
 
You asked the Plan to pay for a routine eye exam. You say that this service should be covered for the enrollee. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
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. 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 a routine eye exam. 
Therefore, we decided that the Plan does not have to pay for a routine eye exam received on December 23, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued use of a pressure reducing mattress.
You asked the Plan to pre-approve the continued use of a pressure reducing mattress. You say that it continues to be medically necessary for the enrollee to have a group 2 pressure relief mattress replacement system for healing and prevention of new ulcerations. The Plan denied your request. The Plan says the information shows that the ulcer has healed, and the mattress is no longer required.
The Plan follows Medicare rules. Medicare rules say that continued use of a group 2 support surface is covered until the ulcer is healed. 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 a pressure reducing mattress. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation provided indicates that the enrollee's ulcer has healed. The pressure reducing mattress is no longer required. 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 a pressure reducing mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued use of a pressure reducing mattress.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (99205, 96127) provided. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there were network providers available. 
 
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 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 physician services (99205, 96127) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from September 14, 2020, to October 
12, 2020. 
 
You asked the Plan to pay for the acupuncture services. You say that the referrals were under the umbrella of 
the Plan. The Plan denied your request. The Plan says acupuncture for neck pain is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you received acupuncture for chronic neck pain not 
chronic low back pain. Therefore, we decided that the Plan does not have to pay for acupuncture provided from 
September 14, 2020, to October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office consultation (99203). 
 
You asked the Plan to pre-approve the office consultation. You say that you want to be seen by the provider 
because you feel that you don't breathe well. The Plan denied your request. The Plan says the records provided 
does not support medical necessity for the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the office consultation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no information provided that substantiates a plastic surgery consultation. 
 
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 office consultation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the outpatient office consultation (99203).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services (99509). 
 
You asked the Plan to pre-approve home health aide services. You say that you need home health aide services. 
The Plan denied your request. The Plan says rules for home health aide services have not been met. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the home health aide services are not medically necessary. Our physician reviewer found the 
documentation does not support that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. In addition, you do not require skilled nursing or rehab services to 
effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance 
program to maintain your condition and/or prevent deterioration. You have been medically stable without any 
recent exacerbations of chronic medical problems or hospitalizations. The requested services for a home health 
aide are custodial and do not require management by a physician. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services (99509).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin based composite (D2332), core build up (D2950), crown (D2740) and resin based composite (D2391).

You asked the Plan to pre-approve resin based composites, core build up and crown. You say that the service is medically necessary. The Plan denied your request. The Plan says the services are not covered benefits.

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. Specifically, the services requested are excluded from the Plan's supplemental dental plan. Therefore, we decided that the Plan does not have to pre-approve resin based composite (D2332), core build up (D2950), crown (D2740) and resin based composite (D2391).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for hyaluronan injections (J7323, J7328)
provided on June 19, 2020, and July 10, 2020.
You asked the Plan to waive the cost-sharing for hyaluronan injections. You say that you believe these charges
are incorrect. The Plan denied your request. The Plan says this processed 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 20%
coinsurance for Medicare Part B drugs.
You have been asked to pay a 20% coinsurance for hyaluronan injections ($753.34 allowed amount x 20% =
$150.67 and $224.75 allowed amount x 20% = $44.95). 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 cost-sharing for
hyaluronan injections (J7323, J7328) provided on June 19, 2020, and July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a disposable sensor represented by code A9276.

You asked the Plan to pre-approve the disposable sensor. You say that the clinical information provided supports the need for the requested sensor The Plan denied your request. 

The Plan says the item in dispute is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that if any of the coverage criteria for the CGM are not met, the related supply allowance will be denied as not reasonable and necessary. 


We looked at the file and Medicare rules. The sensor being requested represents a sensor that is used with a non-therapeutic CGM. Medicare rules only allow coverage for therapeutic CGMs. The sensor being requested is therefore not considered medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the disposable sensor have not been met.Therefore, we decided that the Plan does not have to pre-approve a disposable sensor represented by code A9276
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Givlaari.

You asked the Plan to pre-approve Givlaari. You say that the enrollee needs a higher dose as there is life threatening complications that can arise from uncontrolled porphyria. You say that if the dose is increased the disease will be better controlled and give her a better quality of life.The Plan denied your request. The Plan says that medical necessity was unable to be determined.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Givlaari. Our reviewer says that the documentation supports that Givlaari is medically reasonable and necessary for the enrollee. Our physician reviewer also found that the documentation supports that Givlaari is safe and effective for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Givlaari have been met.Therefore, we decided that the Plan has to pre-approve Givlaari.

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