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

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you 
received on April 26, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that you should not have to pay this 
copayment because you first tried to go to the urgent care center, but it was closed due to COVID-19. The Plan 
denied your request. The Plan says you were charged this copayment 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 $120 
copayment for emergency room services.  
 
You have been asked to pay a $120 copayment for the ER services. This copayment applies regardless of why 
you went to the ER. 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 emergency room (ER) 
services you received on April 26, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the primary care services you received on December 
10, 2019. 
 
You asked the Plan to waive the coinsurance for the primary care services. You say that you are a dual eligible 
enrollee, so you shouldn't have any cost sharing for these services. The Plan denied your request. The Plan says 
that you were charged this coinsurance correctly. 
 
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 enrollees pay a $0 copayment-20% coinsurance for primary care services.  
 
We find this contract language to be vague.  There is nothing in this contract provision that explains when a $0 
copayment would apply for these services vs. when 20% coinsurance would apply.  Furthermore, in the case 
file submitted to us, your Plan has failed to address whether or not you were a dual-eligible enrollee on the 
dates of service in question.  Because the contract language is vague and because the Plan has failed to 
substantiate its argument as to why 20% coinsurance is applicable here, we find that charging the coinsurance 
is inappropriate. Therefore, we decided that the Plan has to waive the coinsurance for the primary care services 
you received on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on May 29, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) rendered by the out of network (OON) provider on May 29, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you are appealing with records. The Plan denied your 
request. The Plan says that the denial of authorization for this drug is correct, because the enrollee does not 
meet the Medicare criteria for Retacrit. 
 
The Plan follows Medicare rules. Medicare rules say that use of ESAs such as Retacrit is only covered under 
certain clinical conditions. 
 
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 Retacrit. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested use of Retacrit. Our physician reviewer found the 
enrollee has multifactorial anemia from chemotherapy treatment (for palliation) and from anemia of chronic 
kidney disease. The enrollee is receiving B12 and bone marrow biopsy showed increased iron stores. 
Therefore, this drug is medically reasonable and 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 Retacrit have been met. Therefore, we decided that the Plan has to pre-approve 
use of Retacrit.  
 
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 pay for acupuncture services received on May 25, 2020. 
 
You asked the Plan to pay for the services. You say that you would like to be reimbursed. The Plan denied your 
request. The Plan says that this is not covered under any circumstances. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The plan's denial is incorrect and out-
of-date, as Medicare now provides limited coverage of acupuncture. The plan did not provide medical records 
from the visit on May 25, 2020 to be able to determine if the visit met the new acupuncture criteria. Therefore, 
we decided that the Plan has to pay for acupuncture services received on May 25, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services from 
January 19, 2020, to January 28, 2020. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation services. You say that you were told 
that you would not owe a copayment for inpatient rehabilitation services. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for days 1-5 for inpatient hospital care.  
 
You received inpatient rehabilitation services from January 19, 2020, to January 28, 2020. This is considered a 
new inpatient hospital admission. Therefore, you are responsible to pay a $275 (copayment) x 5 (inpatient 
days) = $1,375. 
 
You have been asked to pay the total copayment amount of $1,375 for inpatient rehabilitation services. 
Inpatient rehabilitation services fall within the inpatient hospital care 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 inpatient rehabilitation services from January 19, 2020, to January 
28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for that neuromuscular stimulator provided to the enrollee on 
June 1, 2020. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that documentation indicates services are not necessary for treatment of the 
enrollees 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 that neuromuscular stimulator provided to the enrollee on 
June 1, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second night sleep study. 
 
You asked the Plan to pre-approve a second night sleep study. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a second night sleep study is only covered for certain 
indications. 
 
 
 
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 a second night sleep study. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has symptoms that are potentially suggestive of 
obstructive sleep apnea-and the enrollee has so far been referred for attended polysomnography to evaluate for 
obstructive sleep apnea (OSA) (CPT 95810 which has been approved by the health plan). An enrollee can be 
suspected of having OSA, however, diagnostic sleep testing is required in order to establish/"confirm" a 
diagnosis of OSA (be measurement of a AHI/REI). In this case, the enrollee is only suspected of possibly 
having OSA at this time. With the enrollee not having undergone any diagnostic testing to date, it cannot (yet) 
be objectively determined that there is a need for a CPAP device and/or that the enrollee would need to return 
to the sleep laboratory for the a second study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a second night sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a second night sleep study.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit (99203) on May 5, 
2020. 
 
You asked the Plan to waive the deductible for a specialist office visit. You say that you do not agree with the 
provider's billing policies. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $290 deductible for most covered services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
'Physician/Practitioner Services, Including Doctor's Office Visits.' The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $290 deductible for most covered services including office 
visits. This cost sharing is a contractual obligation that had not been met at the time a specialist office visit was 
received on May 5, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a 
specialist office visit (99203) on May 5, 2020.  
 
Your complaint about the provider's policy of billing patients for walking into the clinic 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921). 
 
You asked the Plan to pay for gingival irrigation (D4921). You say that the provider didn't submit prior 
authorization beforehand. You say that the provider knew the service wasn't covered. The Plan denied your 
request. The Plan says the service is not a covered 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, 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 gingival 
irrigation (D4921).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 87641, 87798, and 87900 
provided on December 18, 2019. 
 
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 are not payable as billed. 
 
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 codes 87641, 87798, and 87900 are not supported in the medical record. Specifically, the 
documentation submitted did not include a physician order/lab requisition form or medical records stating 
exactly what tests were to be performed. 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 coded 87641, 87798, and 87900 provided on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 6, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 6, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown provided on November 18, 2019. 
 
You asked the Plan to pay for the crown. The Plan denied your request. The Plan says the documentation does 
not support the medical necessity for the 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. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
documentation provided does not support the need for a crown for tooth #2. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pay for the crown provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on October 3, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysComprehensive Genomic Profile (CGP) testing (i.e. Guardant-360? and NEXT-Generation?) requires use of CPT 81479 (for the entire multi-test panel).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 various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are 
currently unstable. 
 
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 physician reviewer 
found that from a nursing perspective, you received dialysis, required IV pressor support, and IV antibiotics. 
There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a modified 
independent to supervision level with functional mobility. You require varying assist with activities of daily 
living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or skilled 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detection test by nucleic acid for multiple organisms 
(87801) provided on January 9, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for detection test by nucleic acid for multiple organisms. You say that you would 
like this claim reprocessed and approved for payment The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 detection test by nucleic acid for multiple 
organisms (87801) provided on January 9, 2020, by an out of network (OON) provider.