Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) rehabilitation services provided 
from May 24, 2022, to May 31, 2022. 
 
You asked the Plan to pay for SNF rehabilitation services. You say that the hospice provider discharged the 
patient on May 24, 2022. The Plan denied your request. The Plan says Original Medicare would be responsible 
for payment of all Medicare covered services related or unrelated to the members terminal condition. The 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of 
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 24, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for SNF rehabilitation services 
provided from May 24, 2022, to May 31, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay an additional amount for the inpatient hospital services provided on 
December 7, 2020, through January 22, 2021. 
 
You asked the Plan to pay an additional amount for the inpatient hospital services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 
documentation submitted does not support the services billed. 
 
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. Specifically, the Plan has not forwarded any evidence to indicate what specific 
items and services have been denied. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay an additional amount for the inpatient hospital services provided on December 
7, 2020, through January 22, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility care provided on 
July 1, 2022, to July 29, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility care. You say that you were unaware the 
$188.00 per day copayment applied to skilled nursing care. 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 $188 
copayment for days 21 to 100 for skilled nursing facility (SNF) care. You previously received 27 days of SNF 
care in June 2022 to July 2022. This SNF care lasted 18 days, which days 21 to 100 of the SNF benefits period, 
resulting in copayment amount of $XXXX ($188 per day for 18 days = $3,384). You are responsibility to pay 
$2,835, which is less than the $3,384 copayment. 
 
You have been asked to pay $188 copayment for days 21 to 100 for skilled nursing facility care. This 
item/service falls within the skilled nursing facility 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 skilled nursing facility care provided on July 1, 2022, to July 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a respiratory virus panel with 3 to 5 targets (87631) provided on 
January 24, 2022. 
 
You asked the Plan to pay for a respiratory virus panel. You say that this is covered for the enrollee's diagnosis. 
The Plan denied your request. The Plan says that the medical records show that 6 or more pathogens were 
tested, which is 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. Although the Plan states that they requested and received medical records, none 
were included in the submitted case file. Without this documentation, it cannot be verified that this service was 
billed incorrectly. Therefore, we decided that the Plan has to pay for a respiratory virus panel with 3 to 5 targets 
(87631) provided on January 24, 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 procedure code 99407 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 99407. You say that this is separately payable under Medicare as 
billed. The Plan denied your request. The Plan says payment for code 99407 is bundled into payment for code 
90792. 
 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 99407 
is a column II code to column I code 90792.  
 
This claim has not been billed with an appropriate modifier to bypass the edit. It appears that the provider may 
have placed a modifier on the Column 1 code in error. 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 99407 billed 
for date of service July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 12, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 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 office visit provided on July 12, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve premium intraocular lenses for use post cataract 
surgery. 
 You asked the Plan to pre-approve premium intraocular lenses for use post cataract surgery. You say that your 
doctor feels it is necessary for you to get this lens. The Plan denied your request. The Plan says the requested 
services are not a covered benefit under your Medicare Advantage Plan. 
 
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 only covers standard IOLs. 
 
We looked at the file and the Plan's rules. Specifically, you requested to receive premium IOLs, which are 
clearly not covered under your plan. The record also shows that your provider said you can have a standard 
lens without an additional charge, but you will have to pay for the premium lenses, if they will work for you. 
Based on this information, we decided that the Plan's rules for coverage of premium intraocular lenses for use 
post cataract surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve 
premium intraocular lenses for use post cataract surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 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 enrollee was under hospice at the time of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for imaging services provided to the enrollee on October 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit by the Plan or by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hot water bottle (E1399). 
 
You asked the Plan to pre-approve a hot water bottle. You say that you disagree with the denial. The Plan 
denied your request. The Plan says a hot water bottle is not covered because it is not medical in nature and is 
regularly and primarily used by persons who do not have a specific medical need for them. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a hot water bottle (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you need the ramp for you to be able to 
easily move around going outside and inside the house. The Plan denied your request. The Plan says a ramp is 
not covered as durable medical equipment because it is not primarily medical in nature and is not for use in the 
home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules state that for equipment to be covered, it must be appropriate and needed for use 
inside the home.  
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Furthermore, the 
item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare 
nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to 
pre-approve a wheelchair ramp.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-ray provided on May 26, 2022. 
 
You asked the Plan to waive the copayment for X-ray. You say that you are disputing the share cost. 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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $15 copayment for X-ray. This item/service 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 X-ray provided on May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 22, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you are disputing the share 
cost. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $10 copayment for laboratory services. This item/service 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 laboratory services provided on July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Assist device (L8702). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says this device does not meet criteria for coverage since this device is considered 
experimental and 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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the MyoPro 2 Motion G Assist device at issue in this case meets 
all Medicare criteria for medically reasonable and necessary for the 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 
Motion G Assist device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99212) provided on June 13, 2022. 
 
You asked the Plan to pay for a chiropractic office visit. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered chiropractic service under Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan offers an additional benefit that covers one 
chiropractic initial evaluation a year. 
 
The records show that the service at issue is not manual manipulation of the spine or an initial evaluation. 
Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99212) provided on 
June 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility care provided on 
January 5, 2022, to January 19, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility care. You say that you are disputing the 
share cost. 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 
copayment for days 1 to 20 for skilled nursing facility (SNF) care. You previously received 16 days of SNF 
care in January 2022. This SNF care lasted 16 days, which days 1 to 20 of the SNF benefit period, resulting in 
copayment amount of $320 ($20 per day for 16 days = $320). 
 
You have been asked to pay $20 copayment for days 1 to 20 for skilled nursing facility care. This item/service 
falls within the skilled nursing facility 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 skilled nursing facility care provided on January 5, 2022, to January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatry visit provided on July 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a podiatry visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 podiatry visit provided on July 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on 
May 9, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were told by your primary care doctor to get 
hearing aids. You say you were told they would be covered and there would be a copayment for each hearing 
aid. The Plan denied your request. The Plan says the provider was out-of-network. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on May 
9, 2022.
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 02, 
2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you were sent by your primary 
care doctor so it shouldnt charge so 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 $50 
copayment for Urgently needed services. 
 
You have been asked to pay a $50 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 02, 2022.