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

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 5, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 to the enrollee on 
May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that a continuous glucose monitor 
is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, 
K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items are medically necessary. 
The Plan denied your request. The Plan says these are not covered items. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 15, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on February 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-transport ambulance services provided on February 
25, 2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you did not know that you 
would have to pay for the ambulance to come to your home. The Plan denied your request. The Plan says non-
transport ambulance services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The ambulance company did not provide transport services on February 25, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the non-transport 
ambulance services provided on February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on March 4, 
2022. 
 
You asked the Plan to waive the deductible for the lab services. You say that you do not know why insurance 
did not pay any part of the claim. The Plan denied your request. The Plan says the correct amount was applied 
to your deductible. 
 
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 $290 deductible which applies to certain items and services.  
 
The lab services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $290 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the lab services were received on March 4, 2022. Therefore, we decided that the Plan does 
not have to waive the deductible for laboratory services provided on March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
January 27, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on January 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for ultrasounds of arm and leg 
arteries provided on December 20, 2021. 
 
You asked the Plan to waive the deductible and coinsurance for the ultrasounds. You say that you feel that the 
tests were only done due to a house calls visit which was performed incorrectly. The Plan denied your request. 
The Plan says the correct deductible and coinsurance 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 $250 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for radiological diagnostic 
services, including ultrasounds. 
 
The ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the ultrasounds were received on December 20, 2021.  
 
The file shows that on the date of service, you had a total of $89.03 remaining to meet your deductible. This 
amount is applied first. This left a remaining allowed amount of $186.87 for the first ultrasound ($275.90 
allowed amount - $89.03 deductible = $186.87). Of this amount, your responsibility is $37.37, which is 20% of 
the remaining allowed amount ($186.87 remaining allowed amount x 20% coinsurance = $37.37). Finally, your 
responsibility for the second ultrasound is $14.63, which is also 20% of the allowed amount ($73.15 allowed 
amount x 20% coinsurance = $14.63). The total for the deductible and coinsurance is $141.03. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided 
that the Plan does not have to waive the deductible and coinsurance for ultrasounds of arm and leg arteries 
provided on December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered drug provided on April 5, 2022, and 
April 6, 2022. 
 
You asked the Plan to pay for a self-administered drug. You say that the medication you received was given 
while you were in the hospital. The Plan denied your request. The Plan says the self-administered drug is a 
non-covered item or service. 
 
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. Therefore, we decided that the Plan does not have to pay for a self-administered drug 
provided on April 5, 2022, and April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 vaccination provided on October 13, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccination. You say that this claim should be paid. The Plan 
denied your request. The Plan says Original Medicare is responsible for this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare Advantage patients vaccinated in 
2021, providers should submit COVID-19 vaccine administration claims to Original Medicare through the 
Medicare Administrative Contractor.  Providers should use the patient's Medicare Beneficiary Identifier (not 
their Medicare Advantage Plan Member ID) to bill Original Medicare. The COVID-19 vaccination provided to 
a this Medicare Advantage enrollee occurred in 2021, so this claim should be paid by Original Medicare (not 
the Plan.)  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 vaccination have not been met. Therefore, we decided that the Plan does not have 
to pay for the COVID-19 vaccination provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on July 13, 2021.  
 
You asked the Plan to pay for these services. You say that you cannot afford to pay for these services. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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 out of network 
physician services provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on April 19, 
2022, by an OON provider. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that you are requesting a 
reconsideration and you have submitted medical records for medical necessity. The Plan denied your request. 
The Plan says the out-of-network services were not authorized. 
 
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 subsequent nursing facility care visit provided 
on April 19, 2022, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the abdomen provided on February 28, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were not informed there would be a 
$250 copay. You say had you known you would not have gotten the MRI. 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 $250 
copayment for complex radiology.  
 
You have been asked to pay a $250 copayment for an MRI. The MRI 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 magnetic resonance imaging (MRI) of the abdomen provided on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement headgear (A7035) for a Continuous 
Positive Air Pressure (CPAP) machine. 
 
You asked the Plan to pre-approve the replacement headgear. You say that the replacement headgear is 
medically necessary. The Plan denied your request. The Plan says a replacement headgear was already 
provided in the past 6 months. 
 
The Plan must follow Medicare rules. Medicare rules say that quantities of supplies greater than those 
described in the policy as the usual maximum amounts will be denied as not reasonable and necessary. The 
maximum allowed amount for headgear (A7035) is 1 every 6 months. 
 
We looked at the file and Medicare rules. The request is for more frequent replacement of the headgear. 
Medicare rules allow a replacement headgear once every 6 months. Based on this information, we decided that 
Medicare rules for coverage of the replacement headgear have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a replacement headgear (A7035) for a Continuous Positive Air Pressure 
(CPAP) machine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the enrollee is currently stable on this 
medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug plan. 
 
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. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 
Benefits for Ondansetron 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after August 19, 
2022. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says that rules for SNF care have not been met. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not include a valid NOMNC that was delivered two 
or more days before August 19, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit 
is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after August 19, 2022.  
 
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 pay for skilled nursing facility (SNF) services provided to the 
enrollee on May 7, 2021 and May 8, 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 the billed PDPM score does not match what was reported on the admission MDS assessment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The billed PDPM code of NLGE1 and the PDPM score generated from admission MDS assessment - NLXE1 - 
do not match. This decision resulted in a change from the billed PDPM NLGE1 x 21 days to PDPM NLXE1 x 
21 days, as follows: 
 
N" - non-orthopedic surgery, acute neurologic, and PT/OT function score of 6-9. 
"L" - acute neurologic, swallow disorders, and a mechanically-altered diet 
"X" - reduced physical function, nursing function score of 10-14 
"E" - non-therapy ancillary score of 2, coding of malnutrition 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our reviewer found that the enrollee is 
a 97-year-old woman with a history of hypertension and aortic stenosis, who was admitted to the hospital on 
5/4/21 with Cerebral infarction, unspecified. The enrollee had impaired right and left upper and lower 
extremity strength, and required skilled PT service. The enrollee received SNF services from 5/7/21 through 
5/28/21. The enrollee required extensive assistance for bed mobility, transfer, dressing, eating, toilet use, 
personal hygiene, and locomotion on unit. 
 
We looked at this doctor'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 skilled nursing facility (SNF) services provided to the enrollee on May 7, 2021 and May 8, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 18, 2021, and June 8, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on February 18, 2021, and June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72128-26 and 72131-26 billed for date of 
service January 13, 2022. 
 You asked the Plan to pay for procedure codes 72128-26 and 72131-26. You say that the patient had multiple 
exams on this date of service. care."] The Plan denied your request. The Plan says payment for codes 72128-26 
and 72131-26 is bundled into payment for codes 72129 and 72132. 
 
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 codes 
72128-26 and 72131-26 are column II codes to column I codes 72129 and 72132. 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 procedure codes 72128-26 and 
72131-26 billed for date of service January 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered drug provided on December 3, 2021, and 
December 4, 2021. 
 
You asked the Plan to pay for a self-administered drug. The Plan denied your request. The Plan says a self-
administered drug is a non-covered item or service. 
 
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. Therefore, we decided that the Plan does not have to pay for a self-administered drug 
provided on December 3, 2021, and December 4, 2021.