Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the meningococcal vaccine provided on October 27, 2021. 
 
You asked the Plan to pay for the meningococcal vaccine. You say that the doctor felt it necessary to 
administer the vaccine due to having your spleen removed. You say that your conditions compromise your 
immune system and payment should be approved. The Plan denied your request. The Plan says this vaccine is 
not a covered benefit under this plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the meningococcal 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the meningococcal 
vaccine. Therefore, we decided that the Plan does not have to pay for the meningococcal vaccine provided on 
October 27, 2021.  
 
  Benefits for the meningococcal vaccine 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 the copayment for the inpatient hospital stay from April 27, 2021, to 
May 4, 2021. 
 
You asked the Plan the copayment for the inpatient hospital stay. You say that you should not be responsible 
because the hospital changed their course of action and caused you to need a second hospitalization. The Plan 
denied your request. The Plan says the copayment applied is correct. 
 
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 $600 
copayment for each Medicare-covered hospital stay.  
 
 
 You have been asked to pay a $600 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
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 the copayment for the 
inpatient hospital stay from April 27, 2021, to May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable cardiac rhythm monitor 
(33285). 
 
You asked the Plan to pre-approve insertion of an implantable cardiac rhythm monitor. You say that this 
service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage of this service. 
 The Plan follows Medicare rules. Medicare rules say that an implantable cardiac rhythm monitor is covered for 
certain indications listed 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 insertion of an implantable cardiac 
rhythm monitor. Our reviewer says that insertion of implantable cardiac rhythm monitor is not medically 
necessary. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any 
significant cardiac arrhythmias noted. At this time, insertion of an implantable cardiac rhythm monitor would 
not be considered medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an implantable cardiac rhythm monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion of an implantable cardiac rhythm 
monitor (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99214) provided on 
November 22, 2021 . 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
it was a preoperative visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. These services are ineligible to be considered preoperative as they are outside the 1-
day period. 
 
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 $35 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $35 copayment for a specialist office visit. 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 an office visit (99214) provided on November 22, 2021 .
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are not medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
coverage of LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available at 
the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 Opdivo is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of Opdivo in the requested setting has not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Opdivo. Our reviewer says that the 
enrollee does not meet Medicare criteria for coverage of Opdivo. Our physician reviewer found Opdivo is not 
supported for the enrollee's condition in the Medicare accepted compendium. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on May 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99202) provided February 22, 2021. 
 You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there is no established relationship with the ordering provider and the 
enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the files and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for an office visit (99202) provided February 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasound (76705) provided on November 27, 2021. 
 
You asked the Plan to pay for code 76705. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Ultrasound (76705) 
provided on November 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgery on April 28, 2021. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you should not be held responsible for 
your copayment for outpatient surgery because you cancelled the procedure. The Plan denied your request. The 
Plan says the copayment applied is correct. 
 
The rules say that when a procedure is terminated prior to completion due to extenuating circumstances, the 
procedure is still covered by Medicare and beneficiary cost-sharing may be applied to the payment. 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 $380 
copayment for each covered surgery or surgical procedure performed as an outpatient at a hospital. Although 
the record shows that the procedure on April 28, 2021, was not completed, you were prepared for the surgery, 
so the outpatient surgery copayment still applies to this claim. 
 
You have been asked to pay a $380 copayment for the surgery. The surgery falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 surgery on April 28, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 provided any information to support the Plan's reason for the 
denial of payment. We are unable to confirm if the Plan's decision follows Medicare guidelines as the case file 
provided has insufficient information as to the reasoning for the denial of payment for the services provided. 
Therefore, we decided that the Plan has to pay for the laboratory services provided on August 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99202) provided January 29, 2021. 
 You asked the Plan to pay for an office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says there is no evidence of an established relationship between the ordering 
physician and the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for an office visit (99202) provided January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on March 12, 2021. 
 
You asked the Plan to pay for the telehealth services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says telehealth services are not covered when 
provided by an out-of-network provider. 
 
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members 
the benefits offered under the plan including applicable conditions and limitations. 
 
We looked at the file, the Plan's contract, and Medicare rules. The contract clearly says that telehealth services 
are not covered when provided by an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for the telehealth services provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided by an 
OON provider on August 3, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you were told it would be 
$10. The Plan denied your request. The Plan says the copayment applied is correct. The $10 copay you are 
citing in your letter, from page 81 of the EOC, is for lab services from an in-network provider. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copay for each Medicare-covered lab service provided by an OON provider.  
 
 You have been asked to pay a $40 copay for the laboratory services. The laboratory services fall 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 laboratory services provided by an OON provider on August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for rituximab (Rituxan) and hydrocortisone 
injections provided on October 26, 2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were informed by a Medicare 
advisor that the medication was fully covered and would be included with the office visit copayment. The Plan 
denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs. Drug Allowed Amount 20% Coinsurance 
Rituximab (J9312) $8,693.70 $1,738.74 
Hydrocortisone (J1720) $14.81 $2.96 ($1.10 actual charge) 
Total:  $1,739.84 
 
You have been asked to pay $1,739.84, which is slightly less than 20% of the allowed amount for the 
injections. The injections fall within the Medicare Part B Prescription Drugs benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for rituximab (Rituxan) and hydrocortisone injections provided on 
October 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that the services should be covered. 
The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 Outpatient rehabilitation services.  
 
You have been asked to pay a $40 copayment for two PT service visits. the PT 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 
physical therapy (PT) services provided on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on May 19, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says an authorization was not obtained prior to the services 
being rendered, and the provider is not participating with the Plan. The Plan also says that it was determined 
the services were not urgent or emergent in nature. 
 
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 a domiciliary or rest home visit (99336) provided 
on May 19, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection (J0585) 
provided on December 9, 2021. 
 
You asked the Plan to waive the coinsurance for the onabotulinumtoxina injection. You say that the services 
should be covered in full and you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the onabotulinumtoxina injection (allowed is $909 x 20% = 
$181.80), you state in your appeal that you have already paid $80, therefore, you are responsible for the 
remaining charges. Onabotulinumtoxina injections fall within the Medicare Part B prescription drugs benefit 
category. 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 the onabotulinumtoxina 
injection (J0585) provided on December 9, 2021.