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

 
We decided that the Plan does not have to waive the copayments for the medical eye exam and progressive 
lenses provided on May 18, 2022, and June 1, 2022. 
 
You asked the Plan to waive the copayments for the medical eye exam and progressive lenses. You say that 
you believe this second pair of glasses should be covered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
 
 
 The rules say that Medicare does not make separate payment for sales tax. The rules also say that 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 $25 copay for each visit to a 
specialist, and a $65 copay for progressive lenses.  
 
You have been asked to pay a $25 copay for the medical eye exam and a $65 copay, plus $5.84 in tax, for the 
progressive lenses. These services fall within the Vision Care benefit category. This means that you have been 
asked to pay the correct amounts 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 copayments for the medical eye exam and progressive lenses provided on May 18, 2022, and June 
1, 2022.  
 
Please Note: The Plan has requested that the claim be reprocessed because you returned your first pair of glasses 
received on May 18, 2022. The Plan says that your providers office has also been informed of the need to submit 
corrected claims, instead of doing internal adjustments.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 13, 2022. 
 
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 date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be billed with the 
date of specimen collection as the reported date of service; however, there are three exceptions to this rule. The 
rules also 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. Specifically, the Plan has not acknowledged nor addressed the possible 
exceptions to the rule applied in this case. The sample in this case was collected as part of a biopsy procedure 
performed in an outpatient hospital setting, so it is likely that an exception has been met in this case. Therefore, 
we decided that the Plan has to pay for the laboratory services provided on April 13, 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 pay for the infrared therapy (97026) provided from April 25, 2022, 
to April 28, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that this should be covered. The Plan denied your 
request. The Plan says infrared therapy is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided from April 25, 2022, to April 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF services for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF care. The services the 
enrollee requires are called custodial care which is not a Medicare covered benefit. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing (82570 and 83986) provided on 
March 30, 2022. 
 
You asked the Plan to pay for the specimen validity testing. 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 performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the specimen validity testing have not been met. Specifically, we find that the testing described by 
the billed codes is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for the specimen validity testing (82570 and 83986) provided on March 30, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97110) provided on August 26, 2020. 
 
You asked the Plan to pay for the therapy 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 the services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for the therapy services (97110) provided on August 
26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on August 17, 
2021. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you were told they couldnt help 
you at urgent care and sent you to the emergency room so you shouldnt have to pay. 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 $55 
copayment for Urgently needed services. 
 
You have been asked to pay a $55 copayment for urgent care visit. This item/service falls within the Urgently 
needed 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 urgent care visit provided 
on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for OTC COVID-19 test purchased on January 29, 2022. 
 
You asked the Plan to reimburse for OTC COVID-19 test. You say that the covid-19 test should be covered by 
the plan. The Plan denied your request. The Plan says they are not responsible for reimbursing OTC COVID-19 
test. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022, over-the-counter (OTC) 
COVID-19 tests are covered by Original Medicare, so Medicare Advantage plans are not responsible for 
reimbursement of these test. 
 
We looked at the file and Medicare rules. Based on this information, we decided that since this OTC COVID-
19 test was purchased prior to April 4, 2022, the Plan is not responsible for reimbursement of it. Please contact 
the Plan for more information about how to request reimbursement from Original Medicare. Therefore, we 
decided that the Plan does not have to reimburse for OTC COVID-19 test purchased on January 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service May 19, 
2022. 
 You asked the Plan to pay for procedure code 93042. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 12011. 
 
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 93042 
is a column II code to column I code 12011. 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 code 93042 billed for date of service May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is not medically 
reasonable and necessary. The Plan denied your request. The Plan says this procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on May 23, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you dont agree with the copayment 
amount. 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 $125 
copayment for Medicare covered radiological diagnostic services.  
 
You have been asked to pay $74.12 which is less than the standard $125 copayment for CT scan. You already 
paid $25 at the visit so the remaining balance is $49.12. 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. Therefore, we decided that the Plan does not have to waive the copayment for CT scan provided on 
May 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery in a hospital facility 
provided on May 25, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery in a hospital facility. You say that this was in 
the doctors office so you should only be charged the office visit copayment. 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 $250 
copayment for Outpatient surgery. 
 
You have been asked to pay a $250 copayment for outpatient surgery in a hospital facility. This item/service 
falls within the Outpatient surgery benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for 
outpatient surgery in a hospital facility provided on May 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transport, inpatient hospital 
stay, and a MRI provided on May 7, 2022, to May 17, 2022. 
 
You asked the Plan to waive the copayments for ambulance transport, inpatient hospital stay and an MRI. You 
say that this was due to a surgery that went wrong so you shouldn't have to pay for anything. 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 $250 
copayment for ambulance services, $325 per day for days 1 through 6 for each Medicare covered hospital admission/stay and $150 for each Medicare covered diagnostic radiology service. 
 
You have been asked to pay a total of $1,050 copayment for ambulance transport, inpatient hospital stay and an 
MRI. This item/service falls within the Ambulance services benefit category, Inpatient hospital care benefit 
category and 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 copayments for ambulance transport, inpatient hospital stay, and a MRI provided on 
May 7, 2022, to May 17, 2022.
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 at home after recent ankle fracture, managed conservatively, and has 
ongoing trouble ambulating. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
September 13, 2021. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that this is your second bill from 
the same provider and you should not be responsible. 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 $350 
copayment for outpatient surgery. 
 
You have been asked to pay a $350 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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 an outpatient 
surgery provided on September 13, 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 was admitted for bacteremia. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carvykti (BCMA-directed chimeric antigen receptor 
(CAR) T-cell therapy). 
 
You asked the Plan to pre-approve Carvykti (BCMA-directed chimeric antigen receptor (CAR) T-cell therapy). 
You say that Carvykti (BCMA-directed chimeric antigen receptor (CAR) T-cell therapy) is medically 
necessary. The Plan denied your request. The Plan says Carvykti (BCMA-directed chimeric antigen receptor 
(CAR) T-cell therapy) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Carvykti (BCMA-directed chimeric 
antigen receptor (CAR) T-cell therapy). Our reviewer says that Carvykti (BCMA-directed chimeric antigen 
receptor (CAR) T-cell therapy) is not medically reasonable and necessary. Our physician reviewer found that 
Carvykti (BCMA-directed chimeric antigen receptor (CAR) T-cell therapy) is FDA approved for the treatment 
of relapsed or refractory multiple myeloma in adults after 4 prior lines of therapy, including a proteasome 
inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody. Toxicities associated with this 
treatment are high. There is no published data to support CAR T-cell therapy after prior CAR T-cell therapy and is not considered a standard of care. The service is not reasonable or medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Carvykti (BCMA-directed chimeric antigen receptor (CAR) T-cell therapy) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Carvykti (BCMA-directed 
chimeric antigen receptor (CAR) T-cell therapy).