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

 
We decided that the Plan does not have to pay for the dialysis services provided from December 1, 2021, to 
December 30, 2021. 
 
 
 You asked the Plan to pay for the dialysis services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with a missing payer only condition 
code. Based on this information, we decided that Medicare rules for coverage of the dialysis services have not 
been met. Therefore, we decided that the Plan does not have to pay for the dialysis services provided from 
December 1, 2021, to December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service 
February 15, 2022. 
 
You asked the Plan to pay for critical care. You say that this service was reported appropriately and is 
supported in the record. The Plan denied your request. The Plan says the provided medical records do not 
support this service was billed. 
 
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, the CPT Code Manual definition of 
code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. Without this information, a time-based code such as 99291 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of critical care have not been 
met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) billed for date 
of service February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on June 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eyeglasses. You say that the glasses you purchased were good quality and a 
reasonable price. The Plan denied your request. The Plan says the provider that performed these services is not 
in the Plan's network. The Plan also says while you are a member of this plan, you must use network providers 
to get your medical care and services. 
 
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 these services when they are rendered by an in-network optical provider. 
 
We looked at the file and the Plan's rules. These eyeglasses were rendered by an OON provider. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses provided on June 9, 2021, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L5-S1 interlaminar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve an L5-S1 interlaminar epidural steroid injection. You say that you disagree 
with the Plan's 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 an L5-S1 interlaminar epidural steroid 
injection. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee had 70 to 80% pain relief after the lumbar 
epidural steroid injection given on May 13, 2022.  However, the notes indicate that the duration of pain relief 
was approximately three (3) weeks. On the follow-up visit of June 17, 2022, the notes state that the enrollee 
had recently finished the first injection in the lumbar epidural steroid injection series and that the enrollee states 
that there was some benefit from that injection. By the enrollee's visit of June 17, 2022, the enrollee noted that 
pain had returned. The submitted documentation does not show that the enrollee failed to respond well to the 
initial ESI that was done on May 13, 2022 and does not show that the provider intends to use a different approach, level and/or steroid for this injection. 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 an L5-S1 interlaminar epidural steroid injection have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an L5-S1 interlaminar epidural steroid injection (ESI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after July 31, 2022. 
 
You asked the Plan to pre-approve SNF care after July 31, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 after July 31, 2022. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued SNF care. Our physician 
reviewer found continued daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. 
 
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 after July 31, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after July 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care will not provide an adequate 
amount of therapy necessary for the enrollee to make gains toward recovery. You say that the clinical 
documentation provided supports that IRF care is medically necessary. The Plan denied your request. The Plan 
says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the 
services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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 congestive heart failure, pneumonia, and anemia and has been discharged home. There is 
ongoing weakness at home. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect (0013M) provided January 12, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you disagree with this decision and appreciate 
prompt review of this information and authorization of coverage for the CxBladder monitor test. The Plan 
denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. CxBladder Detect has not been evaluated for Medicare coverage by 
the MolDx Program administered by Palmetto GBA. Only CxBladder Monitor has been evaluated and it is 
noncovered. This test is then considered non-covered by Medicare. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder Detect (0013M) provided January 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on December 28, 
2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that this injection should be covered. 
The Plan denied your request. The Plan says the coinsurance applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance of the cost for Part B covered chemotherapy drugs and 20% of the cost for other 
Part B covered drugs. 
 
 
 
 
 The enrollee has been asked to pay $392.28 which is 20% of the allowed amount for an injection. The allowed 
amount is $1,961.40 (20% x $1,961.40= $392.28). Injections fall within the Medicare Part B Prescription 
Drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided 
on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exam provided on April 5, 
2022. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that you thought this was a routine 
eye exam and would have a $0 copayment. The Plan denied your request. The Plan says the copayment applied 
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 $35 
copayment for medical eye exam.  
 
You have been asked to pay $35 copayment for medical eye exam. Medical eye exams fall within the Vision 
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 medical eye exam provided on 
April 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab and Carboplatin. 
 
You asked the Plan to pre-approve Pembrolizumab and Carboplatin. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Pembrolizumab and Carboplatin. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found Pembrolizumab and 
Carboplatin in combination with paclitaxel is indicated for the neoadjvuant treatment of a triple negative breast 
cancer. This enrollee has estrogen receptor/progesterone receptor (ER/PR) positive breast cancer. The service is 
not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab and Carboplatin have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Pembrolizumab and Carboplatin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation from September 20, 
2021, to September 28, 2021. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says the copayment applied was 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 $265 
copayment for inpatient rehabilitation hospital care.  
 
You have been asked to pay the allowed amount of $225.10 which is less than the $265 copayment for 
inpatient rehabilitation. Inpatient rehabilitation falls within the Inpatient Rehabilitation 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 rehabilitation from September 20, 
2021, to September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
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 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on May 24, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you are on a fixed 
income. The Plan denied your request. The Plan says this service is not a covered expense under your dental 
plan. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and 
provider eligibility. 
 
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 the 
problem focused limited oral evaluation (D0140) provided on May 24, 2022.  
 Your complaint about your unhappiness with the Plans coverage is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on February 22, 
2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that this injection should be covered. 
The Plan denied your request. The Plan says the coinsurance applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Part B covered chemotherapy drugs and 20% coinsurance for other Part B 
covered drugs.  
 
 
 
 
 The enrollee has been asked to pay $254.28 which is 20% of the allowed amount for an injection. The allowed 
amount is $1,271.40 (20% x $1,271.40= $254.28). Injections fall within the Medicare Part B Prescription 
Drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided 
on February 22, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve the RFA services. You say that the records provided support the need for 
the injection services being requested. The Plan denied your request. The Plan says the guidelines for coverage 
have not been met. The Plan says that the records do not show that the enrollee has had two medically 
reasonable and necessary diagnostic injections with each one providing at least 80% relief. 
 
The Plan follows Medicare rules. Medicare rules say that RFA services are covered when medically necessary 
for certain clinical indications. 
 
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 RFA services. Our reviewer says 
that the criteria for coverage have not been met Our physician reviewer found the records do not document that 
the enrollee had two prior medial branch blocks that each provided at least 80% sustained pain relief.  The 
review has determined that the requested RFA is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the RFA services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network laboratory services provided 
on February 11, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you had no idea this was out of 
network. The Plan denied your request. The Plan says the copayment applied 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 $65 
copayment for out of network lab services.  
 
You have been asked to pay $65 copayment for lab services. Lab 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 out of network laboratory services provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic services provided on January 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic services. You say that you thought your provider was accepted as in-
network by your insurance plan at the time of your visit. The Plan denied your request. The Plan says they have 
no authorization, and the provider was out-of-network at the time of the visit. 
 
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 diagnostic services at issue in this appeal. The Plan did not pre-approve 
the diagnostic services at issue. We found no exception that would require the Plan to pay for these diagnostic 
services. Therefore, we decided that the Plan does not have to pay for diagnostic services provided on January 
31, 2022, 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 MRI provided on February 24, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you would like this service to be covered. 
The Plan denied your request. The Plan says the copayment applied 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 $195 
copayment for Alameda, Napa, and San Francisco counties, Contra Costa County Enhanced, Santa Clara 
County Basic, or Santa Clara County Enhanced plan members.  
 
You have been asked to pay $195 copayment for MRI. MRIs 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 
MRI provided on February 24, 2022.