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

 
We decided that the Plan does not have to pay for office visit provided on July 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration because medical 
records were submitted for review. The Plan denied your request. The Plan says the enrollees network primary 
care physician (PCP) or plan must give the enrollee approval in advance before they can use providers not in 
the plan's network. This is called giving you a "referral." 
 
 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 11, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4550, A6216, and A6251 billed for date of 
service June 24, 2022. 
 You asked the Plan to pay for procedure codes A4550, A6216, and A6251. You say that the enrollee would 
significantly benefit from the services. The Plan denied your request. The Plan says procedure codes A4550, 
A6216, and A6251 are considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4550 has a status indicator of B, and codes A6216, and A6251 have a status 
indicator of P on the Physician Fee Schedule. This means that procedure codes A4550, A6216, and A6251 are 
not separately payable. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes A4550, A6216, and A6251 
billed for date of service June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit provided on May 5, 2022. 
 
You asked the Plan to waive the cost share for an office visit. You say that you dont believe the billing is 
correct. 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. Your 
contract with the Plan says that there is $800 deductible which applies to office visits and a 10% coinsurance of 
the approved cost for hospital services. 
 
The item or service you asked the Plan to waive the cost share for falls within the Hospital services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $800 
deductible which applies to Hospital services. This cost sharing is a contractual obligation that had not been 
met at the time an office visit was received on May 5, 2022. Therefore, the deductible has been applied. 
 
 
 You have also been asked to pay 10% coinsurance for the office visit. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided the Plan does not have to waive the cost for 
an officed visit provided on May 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray imaging provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for x-ray imaging. You say that this claim should be paid because you feel the exam 
was medically necessary. The Plan denied your request. The Plan says no authorization was obtained prior to 
imaging services being rendered. 
 
  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 x-ray imaging provided on January 27, 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 frames (V2020), photochromatic tint (V2744), anti-
reflective coating (V2750), progressive lens (V2781), and polycarbonate or equal lens (V2784) provided on 
June 17, 2022. 
 
You asked the Plan to pay for the frames and lenses. You say that you feel that since you broke your glasses, 
they should be replaced. The Plan denied your request. The Plan says you bought vision wear on date of service 
July 8, 2021. The Plan also says that this claim denied correctly. 
 
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 1 pair of standard lenses and frames every 2 years. 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you last purchased frames and 
lenses on July 8, 2021, which was less than two years ago, and your eyewear benefit has been exhausted. Based 
on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames (V2020), photochromatic tint (V2744), 
anti-reflective coating (V2750), progressive lens (V2781), and polycarbonate or equal lens (V2784) provided 
on June 17, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the deductible for an emergency room visit provided on January 30, 
2022. 
 
You asked the Plan to waive the deductible for emergency room visit. You say that you should not be held 
responsible for any of the services on this day due to COVID-19. The Plan denied your request. The Plan says 
that the deductible amount you are being charged is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan submitted a copy of the 2022 Summary of Benefits which states that 
certain services are excluded from the deductible which must be referenced in the Evidence of Coverage. 
However, the Plan did not submit a copy of the applicable Evidence of Coverage (EOC). Without a copy of the 
Evidence of Coverage, we cannot determine whether emergency care services are excluded from the Plan 
deductible. Therefore, the Plan has not shown that its decision to apply a deductible to this claim is correct or 
justified according to your contract with the Plan. Therefore, we decided that the Plan has to waive the 
deductible for an emergency room visit provided on January 30, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen accessory, battery pack/cartridge for portable 
concentrator, any type, replacement only (E1356). 
 
You asked the Plan to pre-approve an oxygen battery pack. You say that you are trying to get a longer-lasting 
battery as the current battery only allows two hours of use which is not helpful. Your current battery is not 
working optimally, and your level of O2 has risen to level 3, sometimes 4. You also say that you have a heart 
condition, and you need more than two hours of battery at low strength. The 16 cells battery will allow 6 hours 
of use at your level of use. You would like to breathe somewhat freely for a few hours. The Plan denied your 
request. The Plan says you already have a functioning portable battery pack. Per Medicare guidelines, medical 
equipment may be replaced if equipment is lost or broken. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 The file shows that you have a functioning portable battery pack. The EOC shows that medical equipment may 
be replaced if equipment is lost or broken. A portable battery pack serves the same purpose as an oxygen 
battery pack. Therefore, we decided that the Plan does not have to pre-approve an oxygen accessory, battery 
pack/cartridge for portable concentrator, any type, replacement only (E1356).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablets. 
 
You asked the Plan to pre-approve ondansetron tablets. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B and the Plan 
does not administer the enrollee's Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although the requested ondansetron is an oral anti-emetic that is sometimes covered by 
Medicare Part B, it is only covered by Medicare Part B when administered as part of a cancer chemotherapy regimen. This ondansetron is being requested for a diagnosis of dehydration with no mention of a 
chemotherapy regimen. Although this drug may be helpful for the enrollee, it is not covered by Medicare Part 
B under these circumstances. Therefore, we decided that the Plan does not have to pre-approve ondansetron 
tablets.  
 
Benefits for ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the inpatient care at an IRF due to your 
medical needs. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were 
not met and the enrollee can safely receive the services they need at a skilled nursing facility. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for diarrhea and falls. 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 this 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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on June 13, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that this should have been an urgent care 
copayment and not the ER. 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 $65.33 
copayment for Emergency care. 
 
You have been asked to pay a $65.33 copayment for ER visit. 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. 
You have been asked to pay $65.33 which is less than the standard $110 copayment for ER services. Therefore, 
we decided that the Plan does not have to waive the copayment for ER visit provided on June 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on March 
11, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that this copayment is to high. 
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 $300 
copayment for Outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay a $300 copayment for diagnostic colonoscopy. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center 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 diagnostic colonoscopy provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services (CPT code 98942) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there are two (2) in-network providers that are accepting new patients. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the chiropractic 
services (CPT code 98942) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on February 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that you feel you should not be 
responsible for this bill. You also say that you cannot afford to pay this bill. The Plan denied your request. The 
Plan says the provider in this case does not participate with your primary care provider's (PCP) medical group. 
The Plan also 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 provider in this case does not participate with your primary care physician's (PCP) medical group. 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 the office visit (99215) provided on February 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve a loop recorder. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is covered for the indications established in 
the applicable NCD. 
 
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 a loop recorder. Our reviewer says that 
a loop recorder is not medically reasonable and necessary in this case. Our physician reviewer found that while 
the enrollee has a history of atrial fibrillation and embolic stroke, there is no documentation provided to suggest 
a history of unexplained syncope or any other apparent indication for an ILR. In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a loop recorder have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 You asked the Plan to pre-approve a spinal cord stimulator. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is covered for the indications 
established in the applicable LCD. 
 
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 a spinal cord stimulator. Our reviewer 
says that the requested spinal cord stimulator is not medically reasonable and necessary. Our physician 
reviewer found that detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, the July 28, 2022, examination states 
that the enrollee was able to undergo spinal surgery and then return if the pain continues. The documentation 
does not corroborate that this request is of a late/last resort as there is a consideration for surgery and no 
indication of failure of other treatment modalities. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the requested spinal cord stimulator is not medically reasonable and necessary according to the coverage 
criteria established in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
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 and can be treated in a lower level of care such as home, long-term care facility, or other outpatient setting.

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 genetic testing provided on April 6, 2021 billed with 
codes 81226, 81401, 81225, & 81227. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 6, 2021 billed with codes 81226, 81401, 81225, & 81227.