Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) and visual field exam 
(92083) provided on January 18, 2022. 
 
You asked the Plan to waive the copayment for vision care. You say that the people who were supposed to 
show up to measure your eyes were not there during this visit and you should not owe any money if your eyes 
were not measured. The Plan denied your request. The Plan says this claim was processed correctly, and your 
copayment was assessed in accordance with your contract. 
 
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 
copayment for exams to diagnose and treat diseases and conditions of the eye by an ophthalmologist.  
 
You have been asked to pay a $20 copayment for vision care. The vision services received fall within the 
exams to diagnose and treat diseases and conditions of the eye by an ophthalmologist 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 eye exam (92014) and visual field exam (92083) 
provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic services provided to the enrollee on September 
15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 92136 26 LT (1 unit) remains not supported. 
 
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 92136 is "ophthalmic biometry by partial coherence 
interferometry with intraocular lens power calculation." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found ophthalmic A-scan biometry by 
ultrasound echography is performed through the optical axis of the eye to determine the power of an intraocular 
lens implant. The available documentation in the case file does not support that ophthalmic biometry by partial 
coherence interferometry with intraocular lens power calculation was performed in this case. The case file does not contain documentation for this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ophthalmic services provided to the enrollee on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital services coded 99222 provided on 
December 11, 2021. 
 
You asked the Plan to pay for the initial hospital services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed were previously billed by and paid 
to another provider. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 We find that CPT code 99222 is not supported in the medical record. Specifically, these initial hospital care 
services were previously billed by another provider for this date of service. This means another provider was 
already paid for the service billed. Based on this information, we decided that Medicare rules for coverage of 
the initial hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the 
initial hospital services coded 99222 provided on December 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty hospital bed. 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that the services are 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 a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 heavy-duty hospital bed. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the requested heavy duty hospital bed meets Medicare criteria 
for medically necessary for this enrollee. Provided records do not document that the enrollees condition 
requires positioning of the body; e.g., to alleviate pain, promote good body alignment, prevent contractures, 
avoid respiratory infections, in ways not feasible in an ordinary bed; or the enrollees condition requires special 
attachments that cannot be fixed and used on an ordinary bed. 
 
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 heavy-duty hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a heavy-duty hospital bed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on December 16, 2021, 
December 22, 2021, December 29, 2022, January 13, 2022, January 20, 2022, and January 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that your physicians render care in the facility 
and the service provided was medically necessary. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was 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 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 nursing facility care provided on December 16, 
2021, December 22, 2021, December 29, 2022, January 13, 2022, January 20, 2022, and January 27, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LASIK eye surgery.
You asked the Plan to pre-approve LASIK eye surgery. You say that under the circumstance of what happened
prior and during cataract surgery several things occurred that you believe the Plan should take under consideration and cover the cost of LASIK eye surgery to correct your vision. The Plan denied your request. The Plan says LASIK eye surgery is excluded from coverage.
The Plan contract excludes coverage for eye surgery to reshape the eye for the purpose of correcting refractive defects of the eye such as myopia, hyperopia, or astigmatism.
The services you asked the Plan to pre-approve are considered excluded from coverage with the Plan. Therefore, we decided that the Plan does not have to pre-approve LASIK eye surgery.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapy services provided on June 28, 
2021, and June 29, 2021.  
 
You asked the Plan to waive the copayment for therapy services. You say that you did not have physical or 
occupational therapies during your stay. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing 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 $30 
copayment for physical and occupational therapy services.  
 
The medical record shows you received therapy services on June 28, 2021, and June 29, 2021. You have been 
asked to pay a $30 copayment for therapy services on June 28, 2021 ($22.87 + 7.13 = $30). You have also been asked to pay the allowed amount of $29.43, which is less than the $30 copayment for therapy services on June 
29, 2021. You have been asked to pay a total of $59.43 ($30 copayment + $29.43 copayment = $59.43). 
Therapy services falls 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 therapy services provided on June 28, 2021, and June 29, 2021.
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. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 the enrollee is medically stable with no new and acute medical problems and does not 
need PM&R physician supervision 3 times per week (at a minimum) for the ongoing management of any active 
or acute exacerbations of chronic medical conditions. At the current functional level as described above, the 
enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach in an IRF. The enrollee's rehab needs can be met safely and provided at a 
lower intensity and alternate setting such as in a skilled nursing facility. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve next generation sequencing provided to the enrollee on October 
19, 2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says that panels that include the FANCC gene are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found per the National Comprehensive Cancer Network guidelines for ovarian cancer tumor molecular analysis 
is recommended to include, at a minimum, tests to identify potential benefit from targeted therapeutics that 
have tumor-specific or tumor-agnostic benefit including, but not limited to, BRCA1/2, HR status, MSI, TMB, 
NTRK if prior testing did not include these markers. Molecular profiling is now a standard of care of ovarian 
cancer. The service is reasonable and 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve next generation sequencing provided to the enrollee on October 19, 2021.  
 
 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 4, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you didn't realize you would have 
a copay of $100. The Plan denied your request. The Plan says the copayment 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 $100 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay $100 for the ultrasound. The ultrasound 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 copayment 
for the ultrasound provided on February 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room copayment and self-administered drugs 
provided in an outpatient setting on January 31, 2022. 
 
You asked the Plan to pay for the emergency room copayment and self-administered drugs. You say that you 
never administered any drugs to yourself. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Additionally, you have been asked to pay a $120 copayment for the emergency room 
services. Emergency room services fall within the Emergency 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 pay for the emergency room copayment and self-administered drugs provided in an outpatient setting on 
January 31, 2022.  
 
Benefits for the emergency room copayment and self-administered drugs may be available under Medicare Part 
D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
February 8, 2022, to February 11, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were never put 
into a room and you were put into the hallway with multiple other people. The Plan denied your request. The 
Plan says the copayment 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 $370 a 
day copayment for days 1-5 and a $0 a day copayment for days 6-90 for each inpatient admission per benefit 
period; this includes medical, surgical and rehabilitation services.  
 You have been asked to pay a total of $1,110 ($370 copay x 3 days) for the inpatient hospital services. The 
inpatient hospital 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 hospital services provided from February 8, 2022, to February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a commode. 
 
You asked the Plan to pre-approve a commode. You say that you are in the midst of recovery from a broken 
hip. The Plan denied your request. The Plan says that you do not meet criteria for the requested item. 
 
The Plan follows Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
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 commode. Our reviewer says that the 
documentation supports that the requested commode is medically reasonable and necessary. Our physician 
reviewer found you have a past medical history of right femur fracture and several comorbidities. You were 
hospitalized after a fall resulting in right ankle fracture. It is documented that you are not able to ambulate a 
household distance, thus would be considered confined to a single room. Therefore, you meet criteria for the 
requested commode. 
 
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 commode have been met. Therefore, we decided that the Plan has to pre-
approve a commode.  
 
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: 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. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your therapy needs could be met with intermittent therapy in a custodial 
setting or a supervised home setting with home therapy services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 reviewer says that 
there is no documentation that you require skilled nursing services. You do require skilled therapy services. 
There is no documentation that daily skilled services are required. Although records document you are very 
limited functionally, provided records do not document a significant decline in your functional status compared 
to your recent baseline to necessitate daily inpatient skilled therapy services. There is no documentation that 
you require the services on an inpatient basis, only in a skilled nursing facility setting. Records do not 
document that services in the home with home health care or in a long-term care facility on a part time basis are 
not appropriate in this case. Our physician reviewer found that your condition does not meet Medicare criteria 
for SNF services. 
 
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.