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

 
We decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens (P-C 
IOC) (V2788) provided on March 12, 2020. 
 
You asked the Plan to pay for the P-C IOC. You say that you received an estimate that differed from the final 
cost of the services. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that if an enrollee receives a 
P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C 
IOL and a conventional IOL. 
 
While this service may have been necessary, neither the Plan nor Medicare covers the services you received. 
Therefore, we decided that the Plan does not have to pay for the presbyopia correcting function of intraocular 
lens (P-C IOC) (V2788) provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81226, 81225, 81291, 81227) provided August 
14, 2020. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the correct CPT code was not reported. 
 
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 81226, 81225, 81291, & 81227 is not supported in the medical record. Specifically, per 
the National Correct Coding Initiative Coding Policy, this service should be reported with CPT code 81479. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81226, 81225, 81291, 81227) 
provided August 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face down positioning table (E1399) purchased 
September 2, 2020. 
 
You asked the Plan to pay for the face down positioning table. You say that your doctor prescribed this chair 
for you to be face down. You have already paid for one week and is asking for reimbursement. The Plan denied 
your request. The Plan says this item is considered a precautionary device and is not covered by Medicare. 
 
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 the face down positioning table (E1399) purchased September 2, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy provided form January 
21, 2020, to February 18, 2020. 
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that you disagree with the charges 
and feel that the Plan should cover them. 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 20% 
coinsurance for therapeutic radiology services. 
 
You received radiation therapy from January 21, 2020, to February 18, 2020. Therefore, you are responsible to 
pay your share of the cost-sharing charges. Please see the chart below.  
 
Date of Service Service Allowed Amount Amount You Owe 
1/21/2020 - 1/24/2020 Radiation Therapy  $2,343.28 $468.65 
1/27/2020 Radiation Therapy $270.02 $54.00 
1/27/2020 - 2/4/2020 Radiation Therapy $1,516.69 $303.53 
2/5/2020 - 6/2/2020 Radiation Therapy $1,562.82 $312.55 
2/11/2020 - 2/17/2020 Radiation Therapy $1,884.99 $376.98 
2/18/2020 Radiation Therapy $322.17 $64.43 
 
The total amount you owe is: $1,580.14.  
 
You have been asked to pay the total coinsurance amount of $1,580.14 for radiation therapy. Radiation therapy 
falls within the outpatient diagnostic tests and therapeutic services and supplies 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 radiation therapy provided form 
January 21, 2020, to February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 14 day meter and sensors. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 day meter and sensors. You say that the items are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 
met. 
 
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 Freestyle Libre 14 day meter and 
sensors. Our reviewer says that the items are medically necessary. Our physician reviewer found you are 
prescribed Humalog. You are prescribed strips 3 times per day, so you are likely taking up to 4 shots of insulin 
per day as Lantus does not usually require a blood glucose check. You seem to be adjusting the insulin dose 
according to your blood glucose level as well. 
 
 
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 Freestyle Libre 14 day meter and sensors have been met. Therefore, we 
decided that the Plan has to pre-approve a Freestyle Libre 14 day meter and sensors.  
 
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 physician services provided on October 2, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
member's primary care physician did not refer these 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 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 physician services provided on October 2, 2020 by 
an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging services. 
 
You asked the Plan to pre-approve myocardial perfusion imaging services. You say that a nuclear stress test is 
needed to rule out the possibility of ischemia along with baseline carotid scan to complete the enrollee's 
CHA2DS2-VASc score. The Plan denied your request. The Plan says myocardial perfusion imaging is not 
medically necessary. 
 
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 myocardial perfusion imaging services. 
Our reviewer says that myocardial perfusion imaging services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has some coronary risk but no documented 
chest pain, dyspnea that improved with CPAP, a normal cardiac physical exam and no reported ischemic ECG 
changes. Screening nuclear stress testing has not been shown to improve outcome, even in high risk patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial perfusion imaging services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile x-ray services provided on July 21, 2020. 
 
You asked the Plan to pay for the mobile x-ray services. You say that you billed correctly. The Plan denied 
your request and time expired to review your claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate Place of Service code. 
 
Medicare rules say that when services are provided by a mobile unit, the mobile unit should bill the POS as the 
entity that is being served.  The records provided do not allow the Plan to confirm the appropriate POS code 
was billed for this claim.  Therefore, we decided that the Plan does not have to pay for the mobile x-ray 
services provided on July 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OPDIVO. 
 
You asked the Plan to pre-approve OPDIVO. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 OPDIVO. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found Nivolumab (OPDIVO) is FDA approved 
for the treatment of unresectable advanced, recurrent, or metastatic esophageal squamous cell carcinoma after 
prior fluoropyrimidine- and platinum-based chemotherapy. Use is not supported by major drug compendia or 
the medical literature for adenocarcinoma of the esophagus. The service is not reasonable or 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 OPDIVO have not been met. Therefore, we decided that the Plan does not have 
to pre-approve OPDIVO.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on October 8, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provided. 
 
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 skilled nursing services provided on October 8, 
2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
on November 4, 2020. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree 
with the charges due to the quality of care received. 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 $40 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation 
services fall within the outpatient rehabilitation 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 waive 
the copayment for outpatient rehabilitation services provided on November 4, 2020.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
us to make a decision on this type of complaint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) scans of the 
head and neck rendered October 14, 2020. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient claims must be billed with POS code 
21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue. The claim was not billed with the required 21 POS code. 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 pay for the magnetic resonance angiography (MRA) scans of the head and neck rendered 
October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan has to waive the copayment for emergency care provided from August 16, 2020, to 
August 18, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you do not owe a copayment for 
emergency care if you are admitted inpatient. The Plan denied your request. The Plan says that the claims were 
processed correctly and you are being charged the correct amount. 
 
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 did not provide medical records. Without medical records we cannot 
determine whether or not you were admitted inpatient. Therefore, we decided that the Plan has to waive the 
copayment for emergency care provided from August 16, 2020, to August 18, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a spinal electrical osteogenesis stimulator provided to the 
enrollee on August 25, 2020. 
 
You asked the Plan to pay for the stimulator. You say that this is medically necessary. The Plan denied your 
request. The Plan says this surgery only involved two vertebrae. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 stimulator. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
criteria for bone stimulator is not met. Not enough spinal levels have been fused (3 or more), and there is no 
spinal nonunion documented. The stimulator is not medically needed. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pay for a spinal electrical osteogenesis stimulator provided to the enrollee on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99204) provided on July 8, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services were urgently and needed and 
should be covered. The Plan denied your request. The Plan says even though the services may have been urgent 
in nature, there were in-network providers available that could render the 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. Out-of-network urgently needed care is 
only covered when the network is not available. 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 physician services (99204) provided on July 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99222) provided on September 8, 2019. 
 
You asked the Plan to pay for hospital care. You say that these medically necessary services were provided to 
the enrollee in good faith and that you should not be penalized for delays in the receipt of information from the 
providing facility. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 hospital care was not filed until September 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 hospital care (99222) provided on September 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 62323 provided on March 24, 
2020. 
 
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 62323 is injection(s), of diagnostic or therapeutic 
substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with 
imaging guidance (ie, fluoroscopy or CT). 
 
We find that CPT code 62323 is not supported in the medical record. Specifically, this code was billed with 
place of service 11 (office). However, another claim was billed by a different provider with a place of service 
of 24 (ambulatory Surgical Center). Per the above Medicare guidelines when a physician furnishes services to 
an enrollee in a Medicare- participating ambulatory surgical center (ASC), the place of service code 24 (ASC) 
should be used. Based on this information, we decided that Medicare rules for coverage of the injection 
services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services 
coded 62323 provided on March 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 14, 2020 by an out of 
network (OON) provider. 
 
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 services were 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 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 on July 14, 2020 by 
an out of network (OON) provider.