Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in TTV VAPS mode 
that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. This patient has severe COPD and asthma, 
but there is no documentation of CO2 retention on an arterial blood gas test (ABG) done while the patient is 
stable. There is no evidence that BiPAP has been tried and failed. Certain BiPAP devices can provide the 
volume-assured pressure suppport (VAPS) mode of support, and Medicare does not cover a home ventilator when used as BiPAP. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
25, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider claimed an 
exam and history were done, and you say they were not. 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 $50 
copayment for each in-person specialist visit.  
 You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist office visit provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 18, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you feel that you should 
not have to pay for the services. 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 $45 
copayment for each specialist visit.  
 
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist office visit provided on November 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tremfya 100mg. 
 
You asked the Plan to pre-approve Tremfya. You say that Tremfya is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tremfya 100mg.  
 
Benefits for Tremfya 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit (99205) and the x-ray exam 
of the finger(s) (73140) provided on May 24, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
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 $35 
copayment for each in-person specialist visit and a $35 copayment for each basic imaging service.  
 
 You have been asked to pay $70 ($35 copayment x 2) for the specialist visit and the basic imaging service 
provided. 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 copayments for the office visit (99205) and the x-ray exam of 
the finger(s) (73140) provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided from 
August 13, 2021, to October 15, 2021. We also decided that the Plan does not have to waive the copayment for 
a facet joint nerve destruction procedure performed on October 28, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visits and nerve destruction procedure. 
You say that the provider informed you that there was no copayment required. 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 $5 
copayment for each visit for specialist services, including surgical procedure performed in a physician's office.  
 You have been asked to pay a $5 copayment for each of the specialist office visits and nerve destruction 
procedure, for a total of $15. The specialist office visits and nerve destruction procedure fall within the Doctor 
Visits 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 copayments for specialist office visits provided 
from August 13, 2021, to October 15, 2021. We also decided that the Plan does not have to waive the 
copayment for a facet joint nerve destruction procedure performed on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office service provided on November 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office service. You say that the proper authorization was not obtained prior to 
the service rendered to the enrollee. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network 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 service provided on November 15, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a facet joint injection provided on October 
21, 2021. 
 
You asked the Plan to waive the copayment for the injection. You say that you never had copayments for the 
injection days before. 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 $15 
copayment for specialist services, including medical or surgical services furnished in a physician's office.  
 
You have been asked to pay a $15 copayment for the injection. The injection falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a facet joint injection provided on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital care provided from 
October 11, 2021, through October 13, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
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 for each Medicare-
covered hospital admission/stay, you must pay 10% per stay.  
 
You have been asked to pay $606.91 (Plan allowed amount of $6,069.11 x 10% coinsurance) for the Medicare-
covered inpatient hospital admission provided.  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 inpatient hospital care provided from October 11, 2021, 
through October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on October 
27, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you were not informed of 
any copayments. 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 $30 
copayment for lab services and diagnostic procedures/tests performed in an outpatient hospital facility.  
 
You have been asked to pay $25.23, which is less than the $30 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 October 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on October 25, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that it is up to the facility to get the 
authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network 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 the home health services provided on October 25, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on April 5, 2021. 
 
You asked the Plan to pay for medical nutrition therapy services. The Plan denied your request. The Plan says 
the enrollee does not have a documented diagnosis of diabetes or renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatments to extraspinal regions (98943) 
provided on May 28, 2021. 
 
You asked the Plan to pay for chiropractic treatments to extraspinal regions (98943). The Plan denied your 
request. The Plan says chiropractic treatments to extraspinal regions is not a covered service under Medicare or 
under your Plan's Evidence of Coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We looked at the file and Medicare rules. The only chiropractic service Medicare covers is manual 
manipulation of the spine to correct a subluxation. Therefore, we decided that the Plan does not have to pay for 
chiropractic treatments to extraspinal regions (98943) provided on May 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware of any 
copayment for the services. 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 $40 
copayment for each therapy visit.  
 
The file shows that the Plan reprocessed the claim to reflect the correct copayment. Therefore, you have been 
asked to pay a $40 copayment for the PT services. The PT services fall within the Outpatient Rehabilitation 
Services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy (PT) 
services provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on October 23, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed prior to the check dated  
August 20, 2020. This is within the Medicare timeframe of 1 calendar year after the date of service. Therefore, 
we decided that the Plan has to pay for physician's services provided on October 23, 2019.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 27134 and 20680.  
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 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 
these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found for code 27134 
the documentation does not meet criteria. The operative report documents "Due to the patient age and 
functional status, we would proceed with an isolated head and liner exchange". Operative report describes an 
exchange of head and liner.  The exchange of ball and socket cannot be confirmed. 
 For code 20680 the criteria also re not met. The operative report documents "At this point the four pieces of the 
failed cerclage cables were then removed.  They were all removed in their entirety.  There were four separate 
approaches from to the proximal femur".  The operative report does not describe a separate procedure to 
support billing hardware removal separate from the revision, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for codes and 20680.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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. Our 
physician reviewer found there is no evidence that the enrollee required services that were not available. As 
LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there was no 
advantage in transferring the enrollee to the LTACH. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital services rendered from 
March 15, 2021, to March 16, 2021. 
 
You asked the Plan to waive the coinsurance for inpatient hospital services. You say that this overnight hospital 
stay should have been billed outpatient/observation care, however, the hospital billed your stay as inpatient. 
The Plan denied your request. The Plan says you were 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 20% 
coinsurance for each Medicare-covered hospital stay.  
 
You have been asked to pay $2,019 in coinsurance, which is 20% of the allowed amount for inpatient hospital 
services ($12,416.84 allowed amount x 20% coinsurance = $2,019). Inpatient hospital services falls within the each Medicare-covered hospital stay 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 
inpatient hospital services rendered from March 15, 2021, to March 16, 2021.  
 
Your complaint about potentially having the coded incorrectly 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.