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

 
We decided that the Plan does not have to pay for an office visit provided on January 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you have seen this provider before, and you believe 
they billed wrong. The Plan denied your request. The Plan says the rendering provider is an OON provider and 
there was no referral from an in-network provider 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 office visit provided on January 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. You are ambulating household distances and tending to ADLs with 
minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochromatic tint (V2744), progressive lens (V2781), 
and polycarbonate or equal lens (V2784) provided on March 15, 2022. 
 
You asked the Plan to pay for the photochromatic tint, progressive lens, and polycarbonate or equal lens. You 
say that you had an exam which showed the need to change your prescription, and you replaced the lenses on 2 
pairs of glasses. The Plan denied your request. The Plan says these services exceed the maximum benefit per 
period. 
 
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. The record shows that you received frames and lenses on February 
25, 2022, and your benefit has been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of the photochromatic tint, progressive lens, and polycarbonate or equal lens have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the photochromatic tint (V2744), progressive lens 
(V2781), and polycarbonate or equal lens (V2784) provided on March 15, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from December 22, 
2021, to December 31, 2021. 
 
You asked the Plan to pay for SNF care. You say that these services were pre-approved and were billed 
appropriately. The Plan denied your request. The Plan says that these services cannot be paid as the HIPPS 
code submitted on this claim does not match what was authorized by the Plan. 
 
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. We find that the Plan did not submit a compelling denial rationale in this case. 
The claim was denied due to lack of authorization for the SNF services. However, the Plan has attested that the 
SNF services were authorized with a HIPPS code that was calculated at the time that the approval was 
requested. Based on how the HIPPS code is calculated, however, it is not reasonable to expect or require that 
the code requested for authorization be the code that is billed. The HIPPS code billed must correspond to the 
enrollees actual condition and the services actually rendered during the statement period of the claim. It would 
therefore be expected that the billed code could differ from a code that was estimated prior to the services being 
rendered. The Plan has not made any argument that any of the digits of the billed HIPPS code are incorrect or 
not supported, only that the code as a whole was not approved. We find that this denial of payment has not 
been substantiated. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services 
provided from December 22, 2021, to December 31, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on September 22, 2020. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 20% 
coinsurance for Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $136.32 x 20% = 
$27.26). Oxygen equipment 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 copayment for Oxygen equipment (E0431, E1390) provided 
on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not require specialty nursing wound care or 
daily physician visits. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can be safely administered at the current facility until more appropriate for a lower level of care. The patient 
does not require services at the LTACH that are not already available at the current facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral complete x-ray series (D0210), 2D oral x-rays 
(D0350 x 4), and a panoramic x-ray (D0330) provided on February 28, 2022. 
 
You asked the Plan to pay for the x-rays. You say that you were not advised what services would be covered by 
the insurance. The Plan denied your request. The Plan says intraoral complete x-ray series (D0210), 2D oral x-
rays (D0350), and a panoramic x-ray (D0330) are not covered by your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral 
complete x-ray series (D0210), 2D oral x-rays (D0350 x 4), and a panoramic x-ray (D0330) provided on 
February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes billed are 
included in the dialysis rate. The Plan denied your request. The Plan says the lab testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the home health services. The Plan denied your request. The Plan says this 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 services. Our reviewer says that the 
requested home health aide services are not medically reasonable and necessary. Our physician reviewer found 
that the enrollee does not have documented skilled nursing needs. The enrollee does not have documented 
skilled therapy needs. As such, home health services, including associated home health aide services, are not 
shown to be medically necessary or reasonable. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
October 18, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the medically necessary services were 
provided to the enrollee in good faith. The Plan denied your request. The Plan says the enrollees claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
 
 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 the subsequent nursing facility care (99309) provided on 
October 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that this claim is not a duplicate, and this service 
is supported in the record. The Plan denied your request. The Plan says payment for code 70544 is bundled into 
payment for code 70553. 
 
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 70544 
is a column II code to column I code 70553.  
 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 70544 billed for date of service March 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you would like approval for these services. 
The Plan denied your request. The Plan says there are in-network providers available for these services. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copays for the surgery and rehabilitation services provided 
from March 24, 2021, to March 26, 2021. 
 
You asked the Plan to waive the copays for the services provided. The Plan denied your request. The Plan says 
the claim processed 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).  
 
The file shows that you were charged a $25 copay for outpatient rehabilitation services, and a $350 copay for 
outpatient surgery services. The records show that you paid $200, which leaves a balance of $175. The services 
fall within the outpatient rehabilitation services and outpatient surgery benefit categories. 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 copays for the surgery and rehabilitation services provided 
from March 24, 2021, to March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the extra knee stance feature (L5845) for a College Part Capital 
knee. 
 
You asked the Plan to pre-approve the feature. You say that L5845 is an essential part of the proposed College 
Park Capital Knee. The Plan denied your request. The Plan says that the requested part is unbundled from the 
approved knee and cannot be requested separately. 
 
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 has not definitively proven that L5845 should not be part of the 
approved knee. The plan says that "review of the DME PDAC shows that, while several knees use code L5845, 
College Park Capital Knee is not one of them." The plan has not provided any evidence that the search shows 
the information. Our review of the DME PDAC does not show this. Therefore, we decided that the Plan has to 
pre-approve the extra knee stance feature (L5845) for a College Part Capital knee.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ProText. 
 
You asked the Plan to pre-approve ProText. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are 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 ProText. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has low back pain. There is insufficient literature to establish that the requested 
service is safe and effective for the enrollee's specific clinical condition. Therefore, the enrollee does not meet 
criteria for the requested services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ProText have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ProText.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on March 22, 2021. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 20% 
coinsurance for Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $136.32 x 20% = 
$27.26). Oxygen equipment 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 copayment for Oxygen equipment (E0431, E1390) provided 
on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 16, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that the provider and referring providers are 
participating providers with Medicare. The Plan denied your request. The Plan says the enrollee went to an out-
of-network provider and services were not approved in advance. 
 
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 chiropractic services provided on February 16, 
2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99358) provided on February 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 use of code 99358 is 
not supported by the records provided. Our reviewer found that the attached medical records with claim images 
do not indicate the that an inpatient evaluation and management code was billed with the procedure code 
99358. It is not appropriate to only bill code 99358. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99358) provided on February 23, 2022.