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

 
We decided that the Plan does not have to reduce the copayment for the ophthalmology visit provided on June 
13, 2022. 
 
You asked the Plan to reduce the copayment for the ophthalmology visit. You say that you believe that the 
copayment should only be $45. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Medicare-covered vision services. 
 
You have been asked to pay a $50 copayment for the ophthalmology visit. This item/service falls within the 
Medicare-covered vision 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 reduce the copayment for 
the ophthalmology visit provided on June 13, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, abdomen provided on 
August 4, 2021. 
 
You asked the Plan to pay for radiologic examination, abdomen. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 radiologic examination, abdomen provided on  
August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit on April 6, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not be responsible to 
pay this. The Plan denied your request. The Plan says the copayment has been 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 a $45 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
 
 
 
 
 
 
 
 You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctors 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 visit on April 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan performed on September 28, 
2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not be responsible to pay 
this. The Plan denied your request. The Plan says the copayment has been 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 a $150 
copayment for each visit for a CT scan.  
 
You have been asked to pay a $150 copayment for a CT scan. A CT scan 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 a CT scan performed on September 28, 2021.
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. The Plan denied your request. The Plan says the IRF services you 
are requesting are not supported. 
 
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 enrollee has chronic medical problems with dialysis and oxygen dependence, and 
cannot benefit from intensive rehabilitation as they are non-weight bearing. Recovery from hip fracture and hip 
repair does not require intensive rehabilitation and does not require frequent physiatry oversight. Our reviewer 
found that the enrollee's medical conditions are chronic, generally managed at an outpatient level, do not 
require physiatry oversight. Our physician reviewer also found that the enrollee has access to reasonable and 
necessary rehabilitation services appropriate for their capacity without admission to 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, elbow provided on April 28, 2022. 
 
You asked the Plan to pay for radiologic examination, elbow. The Plan denied your request. The Plan says this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on May 26, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for radiologic examination, elbow have not been met. 
Therefore, we decided that the Plan does not have to pay for radiologic examination, elbow provided on  
April 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the service. You say that the enrollee requires implantation of a spinal cord 
stimulator to address chronic pain symptoms, having tried and failed conservative interventions denoted above. 
The Plan denied your request. The Plan says this surgery is 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have an evidence-based indication for a spinal cord stimulator (SCS) as 
per NCD 160.7. The requested procedure 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care services provided from September 30, 2020, to 
October 26, 2020. 
 
You asked the Plan to pay for the home health care services. You say that the doctor signed and dated the plan 
of care on October 19, 2020. The Plan denied your request. The Plan says that the plan of care must be signed 
and dated by a physician before the claim for each episode of services is submitted for the final percentage 
payment. The Plan also says that the submitted plan of care physician's signature date is illegible and therefore 
not valid. 
 
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. Specifically, we find that the Plan has not submitted a valid denial, as the 
records show a valid signed and dated plan of care for the home health services was submitted. Therefore, we 
decided that the Plan has to pay for the home health care services provided from September 30, 2020, to 
October 26, 2020.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from April 5, 2021, 
to April 10, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the submitted records do not support the billing of principal diagnosis code A41.51. 
 
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 principal diagnosis code A41.51. 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 these services. Our reviewer says that the submitted records 
do not support the billing of principal diagnosis code A41.51. Our physician reviewer found the enrollee 
presented to the hospital with altered mental status. He was described as well-developed, normal pulmonary 
effort, and no respiratory distress. There was no distress due to shortness of breath or diminished respiratory 
effort. While it is acknowledged that the records include a physician-documented diagnosis of sepsis, and that 
Systemic Inflammatory Response Syndrome (SIRS) signs were present along with an elevated lactic acid, the 
clinical findings in the record did not sufficiently support the diagnosis of sepsis based on Sepsis 3 criteria. The 
records therefore do not support the billing of principal diagnosis code A41.51.  
 
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 the inpatient hospital services rendered from April 5, 2021, to April 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient psychosocial rehabilitation services. 
 
You asked the Plan to pre-approve the outpatient services. You say that you suffer from depression and anxiety 
for many years and cannot sleep. Your doctor recommended mental rehabilitation therapies to treat your 
depression. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria 
for outpatient treatment. 
 
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 the outpatient services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee is being treated for Primary Insomnia (F51.01) and Generalized Anxiety 
Disorder (F41.1). Based on review the records provided, it is noted that this enrollee has depressive 
symptomatology for the past 40 years but is able to perform activities of daily living. This enrollee does not 
have any suicidal or homicidal thoughts and does not require inpatient care for Psychosocial Rehabilitation 
Services (PSR). Based on review the records and utilizing LCD L34616, this enrollee does not require inpatient 
care for the treatment utilizing Psychosocial Rehabilitation Services (PSR) but could be treated on an outpatient 
basis by her doctor along with therapy and therefore is not considered 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 the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve outpatient psychosocial rehabilitation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified 
probe technique provided on January 27, 2022. 
 
You asked the Plan to pay for infectious agent detection by nucleic acid (DNA or RNA); severe acute 
respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe 
technique. The Plan denied your request. The Plan says payment will be reconsidered whenever the explanation 
of benefits is provided by the primary insurance carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the explanation of benefit from the primary insurance carrier.  As the secondary insurer, the Plan cannot be 
held responsible for infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory 
syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique. until 
the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have 
to pay for infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome 
coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique provided on 
January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a compression glove with thumb and finger stubs 
identified with code A6549. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a compression glove 
with thumb and finger stubs identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom sleep apnea appliance (D9948) provided on 
February 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that it is medically necessary to have this dental 
procedure done. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the custom sleep apnea appliance is not covered by the Plan. 
 
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 a custom 
sleep apnea appliance (D9948) provided on February 17, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Pembrolizumab (J9271) provided on November 23, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the Pembrolizumab. You say that this service was provided in good faith, was 
necessary and reasonable, and you would like payment to be rendered. The Plan denied your request. The Plan 
says that prior authorization was not obtained prior to rendering services. 
 
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 record shows that the Plan denied this service because this service was 
rendered by an OON provider, and prior authorization was not obtained. The 2021 Evidence of Coverage 
clearly states that a referral or prior authorization is not required to receive care OON. The contract does not 
clearly state that prior authorization is required for the drug that was administered. Therefore, we decided that 
the Plan has to pay for the Pembrolizumab (J9271) provided on November 23, 2021, by an out-of-network 
(OON) provider.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing provided on October 23, 
2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the clinical 
value has not been demonstrated. 
 The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We looked at the file and Medicare rules. The medical records do not show that the testing was ordered for a 
specific medical problem. Medications should be provided based on the presence of a diagnosis and should be 
adjusted based on a patient's response to the medication. Furthermore, genetic markers may or may not 
correlate with actual clinical findings. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the 
pharmacogenomics testing provided on October 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission for an approved Total Knee 
Arthroplasty. 
 
You asked the Plan to pre-approve the inpatient admission. You say that the inpatient stay is medically 
necessary. The Plan denied your request. The Plan says this procedure can safely be performed in the outpatient 
setting. 
 
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 the inpatient admission. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the plan approved the left total knee replacement as an outpatient procedure. Records 
do not show a medical history that would clearly place this enrollee at increased risk for peri-surgical 
complications requiring an inpatient stay. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission for an approved Total Knee Arthroplasty.