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

 
We decided that the Plan does not have to pay for an outpatient hospital visit provided on October 20, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient hospital visit. You say that the service was provided to the enrollee 
out of medical necessity and the claim should be paid because the hospital is an authorized provider. The Plan 
denied your request. The Plan says the rendering provider is an out-of-network provider and there was no 
referral from the enrollee's primary care physician or an approved authorization. Also, the service rendered was 
not urgent or emergent. 
 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 an outpatient hospital visit provided on October 
20, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided on November 20, 2020. 
 
You asked the Plan to waive the copayment for an ECG. You say that you disagree with the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for diagnostic procedure or test.  
 
You have been asked to pay the allowed amount $17.63, which is less than the $50 copayment for an ECG. An 
ECG 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 an ECG provided on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services: medical examination and 
evaluation (92014) provided on October 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services: medical examination and evaluation. You say that at 
this time it is important to clarify that the patient did not have any input in choosing who would be his 
optometrist, and instead he blindly relied on the facility's staff to ensure that he would have a vision exam, 
which was of high necessity. You also say that a provider performing services in a nursing home facility is not 
responsible to obtain authorization. The Plan denied your request. The Plan says this provider is out-of-network 
with the Plan, and authorization was not obtained prior to the 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 ophthalmological services: medical examination 
and evaluation (92014) provided on October 20, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on May 
13, 2021, to May 20, 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 DRG remains not supported.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 432 (CIRRHOSIS AND ALCOHOLIC 
HEPATITIS WITH MCC). We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found the enrollee presented to the emergency department (ED) with back pain and abdominal 
distention with evidence of cirrhosis and ascites with pleural effusion on evaluation requiring thoracentesis. 
Vitals showed hypertension and tachycardia, however Spo2 was 94% on room air  and was only given low 
dose oxygen support without other signs or symptoms of acute respiratory failure to meet criteria for this 
diagnosis. Therefore, the DRG 433 was supported in the medical records for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee on May 13, 2021, to May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on December 
2, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you thought the lab work 
was processed at a stand-alone laboratory. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for laboratory services provided at an outpatient hospital setting.  
 
The file shows that the Plan confirmed the place of service as an outpatient hospital. Therefore, you have been 
asked to pay a $25 copayment for the laboratory services. The laboratory services fall 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 December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom shoe inserts (orthotics) (CPT code L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show 
that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be 
appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, 
we decided that the Plan does not have to pre-approve the custom shoe inserts (orthotics) (CPT code L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table (E0274). 
 
You asked the Plan to pre-approve the over-bed table. You say that this device is medically necessary. The 
Plan denied your request. The Plan says an over-bed table is considered a convenience item and is non-covered. 
 
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 an over-bed table (E0274).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
April 3, 2021, to April 8, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not 
understand why these bills were not paid in full. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 per 
day for days 1-6 and $0 per day for additional days for each hospital admission.  
 
 The file shows that you were in the hospital from April 3, 2021, to April 8, 2021, but there is no copayment for 
the discharge date. Therefore, you have been asked to pay $225 per day for the first 5 days of inpatient hospital 
services. The total for your stay is $1,125 ($225 copayment x 5 days = $1,125). The inpatient hospital services 
fall within the Inpatient Hospital 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 
inpatient hospital services provided from April 3, 2021, to April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided from 
February 2, 2021, to July 29, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you used to pay nothing. The 
Plan denied your request. The Plan says the cost-sharing rules were applied 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 DME and related supplies.  
 
 
  Date of Service Service/Item Allowed Amount Cost-Share per 
Contract 
Your Cost-Share 
Responsibility 
February 2, 2021 Face mask interface $126.69 20% coinsurance $25.34 
February 2, 2021 Filter $16.08 20% coinsurance $3.22 
July 28, 2021 Face mask interface $128.07 20% coinsurance $25.61 
July 29, 2021 Filter $16.26 20% coinsurance $3.25 
Total:    $57.42 
 
You have been asked to pay 20% coinsurance for the CPAP supplies. The CPAP supplies falls within the 
Durable medical equipment (DME) and related 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 coinsurance for the CPAP supplies provided from February 2, 2021, to July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (83789) provided on March 5, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 83789 
is a column II code to column I code 80307. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (83789) provided on March 
5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on November 8, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you do not know why you are being 
charged. The Plan denied your request. The Plan says the copayment amount charged is correct. 
 
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 per visit for all other outpatient diagnostic and therapeutic service and supplies, such as CT scans.  
 
You have been asked to pay a $135.24 copayment, which is less than the Plan's EOC documented $250 
copayment for a CT scan. CT scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography 
(CT) scan provided on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 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 use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick external female catheters. 
 
You asked the Plan to pre-approve Purewick external female catheters. You say that this is a necessary 
alternative to other incontinence supplies. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that female external urinary collection devices are 
covered for beneficiaries who have permanent urinary incontinence when used as an alternative to an 
indwelling catheter. 
 
We looked at the file and Medicare rules. The submitted documentation does not show that the requested 
devices are being used as an alternative to an indwelling catheter. Based on this information, we decided that 
Medicare rules for coverage of Purewick external female catheters have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Purewick external female catheters.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 23, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that POS 81 is correct for this service. The 
Plan denied your request. The Plan says the POS code does not match the location in which the sample was 
collected as required. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 Guardant360 testing 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 the Guardant360 testing provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on September 20, 2021. 
 
You asked the Plan to pay for the critical care services. You say that it is felt that these records are supportive 
of the coding for this claim. The Plan denied your request. The Plan says time is not documented so critical 
care payment is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that for each date and encounter entry, the physician's 
progress note(s) shall document the total time that critical care services were provided. 
 
The progress note submitted for review does not document the time spent providing critical care services. 
Therefore, we decided that the Plan does not have to pay for the critical care services provided on September 
20, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz Fx. 
 
You asked the Plan to pre-approve Supartz Fx. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Supartz Fx. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the documentation does not outline 
contraindications or reasons these medications were not considered or that one of the plans required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the 
documentation, Supartz FX is not approved, as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz Fx have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz Fx.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination provided on November 30, 2021. 
 
You asked the Plan to pay for the eye examination. The Plan denied your request. The Plan says this service is 
not covered out-of-network. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the eye exam was provided by an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of the eye examination have 
not been met. Therefore, we decided that the Plan does not have to pay for an eye examination provided on 
November 30, 2021.