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

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network specialist visit provided 
on March 31, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network specialist visit. You say that you should not 
have to pay this coinsurance. The Plan denied your request. The Plan says the coinsurance 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 50% 
out-of-network coinsurance for point-of-service for a specialist (50% of the allowed amount of $451 is 
$225.50).  
 
You have been asked to pay a $225.50 out-of-network coinsurance for an out-of-network specialist visit. An 
out-of-network specialist visit falls within the point-of-service for a specialist 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 an out-of-network specialist visit provided on March 31, 2022.  
 Your complaint about the provider being so far away 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81003, 80053, G0471, 
82306, 84443, 82607, 82746, 85025, 83540, 83550, 82728, 83036, P9604, 80061 provided on February 28, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee's specimens were sent to your 
laboratory as per order from the in-network referring provider. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 81003, 80053, 
G0471, 82306, 84443, 82607, 82746, 85025, 83540, 83550, 82728, 83036, P9604, 80061 provided on February 
28, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special stain including interpretation and report (88313) 
provided March 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that special stains are only ordered as deemed 
medically necessary to provide a complete and accurate diagnosis to the treating physician to direct treatment. 
The Plan denied your request. The Plan says there is not sufficient documentation showing why the Alcian 
Blue stain was completed. 
 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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a history of GERD with esophagitis. There 
was no specific clinical rationale for why the Alcian Blue stain was completed. Per the coverage criteria it is 
not medically necessary or reasonable to perform the Alcian Blue stain if clinically meaningful intestinal 
metaplasia is present. The review has determined that the records do not support that the services was 
medically necessary for the enrollee and meets Medicare coverage. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the special stain including interpretation and report (88313) provided March 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a duplex scan (ultrasound) of extremity 
veins provided on February 1, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you feel the service should be 
billed as an office visit. 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 $170 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay a $170 copayment for the ultrasound. The ultrasound 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 reduce 
the copayment for a duplex scan (ultrasound) of extremity veins provided on February 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 February 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air mattress (E0277) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the air mattress. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they are non-
emergent and care can be provided in-network. 
 
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 
an air mattress (E0277) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on September 24, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that non-participating providers are required to furnish necessary information to the health plan 
when requested. 
 
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's denial has not been substantiated. The provider has submitted medical 
records to support these services, including the actual laboratory records and results, plus the progress notes for 
the same date of service that led to the labs being ordered. Enough information has been submitted to verify the 
services. Therefore, we decided that the Plan has to pay for laboratory services provided to the enrollee on 
September 24, 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: 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 the enrollee does not have documented 
skilled nursing needs or documented skilled therapy needs. The enrollee appears unable to participate in daily 
skilled therapy. Daily skilled services are not shown to be required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. The enrollees care needs, 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: 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 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 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 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that you require the services on an inpatient basis, only in a skilled nursing facility 
setting. Records do not document those services in the home with home health care or in a long-term care 
facility on a part time basis are not appropriate in this case. 
 
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: 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet IRF criteria. 
 
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The enrollees care needs can be met 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth services provided from  
February 1, 2022, to April 5, 2022. 
 
You asked the Plan to waive the copayment for telehealth services. The Plan denied your request. The Plan 
says the copayment applied correctly to the claims. 
 
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 Physician/Practitioner Services, Including Doctors Office Visits.  
 
You have been asked to pay a $5 copayment for telehealth services. The telehealth services 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 the contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to 
waive the copayment for telehealth services provided from February 1, 2022, to April 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vidaza. 
 
You asked the Plan to pre-approve Vidaza. You say that the services are necessary. The Plan denied your 
request. The Plan says routine costs associated with clinical trials are not covered. The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Vidaza as part of a clinical trial. The Plan does not cover routine 
costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Vidaza.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from February 25, 2019, 
to March 1, 2019, at the diagnosis related group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient services at the DRG originally billed.. You say that this diagnosis 
was supported in the record. The Plan denied your request. The Plan says the principal diagnosis of O99.13 
(anemia complicating pregnancy, third trimester) is not supported in the medical record, resulting in a lower 
DRG. 
 
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 the principal diagnosis of O99.13 (anemia 
complicating pregnancy, third trimester). We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient services at the DRG originally billed. Our reviewer says that the principal diagnosis of O99.13 
(anemia complicating pregnancy, third trimester) is not supported in the medical record. Our physician 
reviewer found the enrollee was a then 26-year-old woman with who was admitted to the hospital with positive 
fetal movements, uterine contractions, with no vaginal bleeding or rupture of membranes. The vaginal exam 
showed that she was 75% effaced and 4 cm dilated. The enrollee was admitted with pre-term labor and an 
intrauterine pregnancy of 33.5 weeks. In the discharge summary it is noted that the enrollee was anemic so she 
was admitted to the hospital. The enrollee was treated with full dose steroids and 24 hours of magnesium 
sulfate. There was no cervical change while in the hospital. The enrollee was discharged on bed rest, pelvic 
rest, and follow-up. The principal diagnosis of anemia complicating pregnancy, third trimester (O99.013) is not 
supported. In episodes when no delivery occurs, the principal diagnosis should correspond to the principal 
complication of the pregnancy which necessitated the encounter. The documentation in the History and 
Physical dated February 25, 2019, supports "pre-term labor" as the "Reason for admission" and consequently is 
the principal diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from February 25, 2019, to March 1, 2019, at the diagnosis related 
group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthesis with a computerized foot and knee. 
 
You asked the Plan to pre-approve a prosthesis with a computerized foot and knee. 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 follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee 
is covered for beneficiaries whose functional level is 3 or above. 
 
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 prosthesis with a computerized foot 
and knee. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
on the medical records provided there is no documentation that the computerized foot and knee at issue in this 
case meet the Local Coverage Determination (LCD): Lower Limb Prostheses - L33787 criteria for medically 
reasonable and necessary. Provided medical records do not clarify why the microprocessor foot and knee are 
medically necessary and why a mechanical K3 level foot and knee will not meet your needs. The letter of 
medical necessity addressing this issue is not considered part of the medical record for determining medical 
necessity per Medicare rules. 
 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 prosthesis with a computerized foot and knee have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a prosthesis with a computerized foot and knee.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rental months for oxygen concentrator 
(E1390) and portable gaseous oxygen system (K0738). 
 
You asked the Plan to pre-approve additional rental months for oxygen concentrator and portable gaseous 
oxygen system. You say that the items are necessary. The Plan denied your request. The Plan says the rental 
benefit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment during the 5-year reasonable useful lifetime (RUL) of the equipment after 36 rental payments have 
been made.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional rental months for oxygen concentrator and portable gaseous oxygen system have not 
been met. Therefore, we decided that the Plan does not have to pre-approve additional rental months for 
oxygen concentrator (E1390) and portable gaseous oxygen system (K0738).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dronabinol. 
 
You asked the Plan to pre-approve Dronabinol. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Dronabinol.  
 
Benefits for Dronabinol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.