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

 
We decided that the Plan does not have to pay for the office visit (99213), chiropractic manipulative treatment 
(98941), and the mechanical traction therapy (97012) rendered by the out-of-network (OON) provider on  
May 4, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 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. The Plan did not pre-approve the services 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 the office visit (99213), chiropractic manipulative 
treatment (98941), and the mechanical traction therapy (97012) rendered by the out-of-network (OON) 
provider on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on April 04, 
2022, to May 13, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that this was a part of your treatment 
so it should be covered. The Plan denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for Medicare Part B prescription drugs. 
 
You have been asked to pay a $35 copayment for radiation therapy. This item/service falls 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. You have been asked to pay a total of $745 copayment for all of your radiation therapy 
treatments. Each treatment had a $35 copayment except for the last one when you were only charged a $10 
copayment due to reaching your out-of-pocket maximum. Therefore, we decided that the Plan does not have to 
waive the copayment for radiation therapy provided on April 04, 2022, to May 13, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on August 17, 2021, to August 31, 
2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the clinical 
diagnosis. The Plan denied your request. The Plan says that the DRG should be downgraded. 
 
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. 
 
We looked at the file and the rules. The Plan downgraded the DRG from 871 to 64. The Plan did not provide 
documentation to show the primary diagnosis code was not supported. The case file does not show that the Plan 
made any attempts to obtain additional information. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that 
the Plan has to pay for inpatient hospital services provided on August 17, 2021, to August 31, 2021, at the 
Diagnosis Related Group (DRG) originally billed.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the right 
shoulder (73221). 
 
You asked the Plan to pre-approve an MRI of the right shoulder. You say that you feel this service is medically 
necessary. The Plan denied your request. The Plan says this service is not medically necessary since plain films 
were not performed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when 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 an MRI of the right shoulder. Our 
reviewer says that an MRI of the right shoulder is not reasonable and necessary. Our physician reviewer found 
there is no clinical evaluation or history in the submitted records. An x-ray report for a cervical spine series is 
in the file but no right shoulder series. Our reviewer also found that there is insufficient documentation to 
assess medical necessity for the requested MRI of the right shoulder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the right shoulder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the right shoulder (73221).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that that you cannot be released from the hospital without 
IRF care. The Plan denied your request. The Plan says IRF is not medically necessary and the services you 
need can be provided safely in other settings. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that the enrollee is taking Metformin, Rybelsus, 
Treshiba, and is diabetic. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for a therapeutic CGM. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on May 10, 2021. 
 
You asked the Plan to pay for the surgical pathology services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
  
We find that CPT code G0416 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 1. This claim was billed with a place of service 22 (outpatient hospital). 
The professional interpretation was furnished in the same payment locality from where the TC was furnished. 
We find that the Medicare rule for payment of this claim has not been met as the professional interpretation of 
a diagnostic test must be separately billed with modifier  26 by the interpreting physician. This means this 
claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical pathology services provided on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (84443), lipid panel 
(80061), and comprehensive metabolic panel (80053) provided on April 23, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 did not pre-approve the services 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 the thyroid stimulating hormone (84443), lipid panel (80061), and 
comprehensive metabolic panel (80053) provided on April 23, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee shows motivation and would benefit 
from an inpatient rehabilitation program. Inpatient rehabilitation is necessary due to uremia, urinary tract 
infection, requiring intravenous antibiotics, renal impairment and cirrhosis. The Plan denied your request. The 
Plan says based on Medicare guidelines the inpatient rehabilitation facility services you are requesting do not 
meet the requirements for approval. 
 
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 was admitted for discitis, bacteremia, and mitral valve endocarditis. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. Medically necessary care can be provided in a different level of care. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on June 07, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you shouldnt have to pay this much. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $165 
copayment for Radiological diagnostic services. 
 
You have been asked to pay a $165 copayment for MRI. This item/service falls within the Radiological 
diagnostic 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. You have been asked to pay $136.66 which is less than the standard $165 copayment for MRIs.  
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to waive the copayment for MRI provided on June 07, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care services on February 27, 
2022, to March 14, 2022. 
 
You asked the Plan to waive the copayment for emergency care services. You say that you would like to appeal 
the cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 $90 
copayment for emergency care services.  
 
You have been asked to pay a $90 copayment for emergency care services. This item/service falls 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 waive the copayment for emergency care services on 
February 27, 2022, to March 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Benlysta infusions. 
 
You asked the Plan to pre-approve the Benlysta infusions. You say that you would like reconsideration because 
the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for coverage of the requested drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the Benlysta infusions. Our reviewer 
says that the records do not confirm that this enrollee is autoantibody-positive with the indeterminant anti-
double stranded Deoxyribonucleic Acid (DNA) result and an anti-nuclear antibody result with no quantitative 
titer. The use of Benlysta for lupus without evidence of autoantibody-positivity is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician 
reviewer found the use of Benlysta for lupus without evidence of autoantibody-positivity does not meet 
Medicare criteria for safe and effective and otherwise reasonable and necessary for this enrollee. 
 
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 Benlysta infusions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Benlysta infusions.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a spherocylinder trifocal lens (V2303), deluxe frames (V2025), vision 
services frames (V2020), progressive lenses (V2781), anti-reflective coating, per lens (V2750), and 
polycarbonate per lens (V2784) provided on May 9, 2022. 
 
You asked the Plan to pay for a spherocylinder trifocal lens (V2303), deluxe frames (V2025), vision services 
frames (V2020), progressive lenses (V2781), anti-reflective coating, per lens (V2750), and polycarbonate per 
lens (V2784). You say that you had cataract surgery on February 7, 2022, April 6, 2022, and a post operative 
appointment on May 9, 2022. You also say that on May 9, 2022, you ordered new glasses, and were directed to 
the glasses that were Medicare allowed, using the allowance available. The Plan denied your request. The Plan 
says that per the EOC for vision service, there is a $175 allowance for supplemental eyewear. The Plan also 
says that members are responsible for all costs over and above the allowance amount. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens. The Plan also says they cover a $200 allowance for supplemental eyewear 
every year. 
 
We looked at the file and the Plan's rules. The Plan did not provide any information to show that the first pair 
of glasses (1 unit of spherocylinder trifocal lens (V2303) and the vision service frames (V2020)) were not 
provided following cataract surgery. The second pair of glasses should also be covered up to $200 (as stated in 
the EOC instead of $175). The record shows the billed amount for deluxe frames (V2025) was $25, the billed 
amount for the progressive lenses (V2781) was $24, the billed amount for anti-reflective coating per lens 
(V2750) was $70, and the billed amount for polycarbonate per lens (V2784) was $79, which is a total of $198. 
The billed amount for the second pair of glasses is less than the $200 allowance. Based on this information, we 
decided that the Plan's rules for coverage of spherocylinder trifocal lens (V2303), deluxe frames (V2025), 
vision services frames (V2020), and progressive lenses (V2781) have been met. Therefore, we decided that the 
Plan has to pay for a spherocylinder trifocal lens (V2303), deluxe frames (V2025), vision services frames 
(V2020), progressive lenses (V2781), anti-reflective coating, per lens (V2750), and polycarbonate per lens 
(V2784) provided on May 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection provided on January 18, 2022. 
 
You asked the Plan to waive the coinsurance for injection. You say that you never had to pay this much in the 
past so you shouldnt have to now. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for Part B covered prescription drugs. 
 
You have been asked to pay 20% coinsurance for injection. This item/service falls within the Part B covered 
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 injection provided 
on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on June 1, 2022.