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

 
We decided that the Plan does not have to pay for an office visit provided on October 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the enrollee's plan switched, and you did not know a 
referral was needed. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no prior approval to see an out-of-network provider. Also, the services provided were 
not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on October 22, 2021, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission for an electroencephalogram (EEG). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the hospitalization to perform this monitoring does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.  Our physician reviewer found you have a history of uncontrolled atypical seizures. There is no documentation 
provided necessitating inpatient level of care services for the procedure. There is no indication of required 
inpatient diagnostic procedures or therapeutic interventions. The review has determined that the enrollee does 
not need an inpatient stay for the EEG. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient admission for an electroencephalogram (EEG).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 6, 2021, through 
July 10, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that 
based on the records we have, this might be an observation stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from July 6, 2021, through July 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has cervical spondylosis 
with pain at the base of skill on the left radiating around the head. She underwent a medial branch block (MBB) 
on November 24, 2021 and January 13, 2022 with positive results. The MBBs were performed at only one 
level, C2 to C3. There is no clinical documentation submitted demonstrating the medical necessity for 
treatment of a second level. The requested RFA is not medically reasonable or necessary at the left C3-C4 
level. We looked at this physician'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 pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine and administration provided on 
November 9, 2021. 
 
You asked the Plan to pay for the shingles vaccine and administration. You say that you were told the shot was 
covered but you might have to pay $55 to $100. You say that you would not have scheduled the shot if you 
knew it wouldn't be covered and this is too expensive for you to cover. The Plan denied your request. The Plan 
says vaccinations and their administration fee are a Part D covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine and administration. Therefore, we decided that the Plan does not have to pay for the shingles vaccine 
and administration provided on November 9, 2021.  
 
  Benefits for the shingles vaccine and administration 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on 
September 22, 2021. 
 
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan 
says the total cost for the eyeglasses was $804. The benefit of $150 allowance was applied to the purchase, 
leaving a members responsibility of $654. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows Plan says the Plan benefit of $150 allowance was 
applied to the purchase, leaving a members responsibility of $654. Therefore, we decided that the Plan does 
not have to pay an additional amount for eyeglasses provided on September 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 19, 
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 code 70450 has an unbundled relationship with procedure code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 power operated vehicle. You say that a power operated vehicle is 
necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a manual wheelchair. This means that Medicare rules 
for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 1 power operated vehicle (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings (A6545) provided on March 4, 2021. 
 
You asked the Plan to pay for compression stockings. You say that the items at issue are a necessity for your 
care. The Plan denied your request. The Plan says rules for payment have not been met because the provider at 
issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for compression stockings (A6545) 
provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a laparoscopy and IV therapy and does not 
have to waive the coinsurance for Medicare Part B drugs and medical supplies provided from June 18, 2021, to 
August 26, 2021. 
 
You asked the Plan to waive the copayments for a laparoscopy and IV therapy, and to waive the coinsurance 
for Medicare Part B drugs and medical supplies. You say that you disagree with how the Plan processed the 
charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being 
charged the correct 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 $325 
copayment for outpatient surgery and other medical services and provided at hospital outpatient facilities and 
ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay 20% coinsurance 
for Medicare Part B prescription drugs and medical supplies. 
 
You received a laparoscopy, IV therapy, Medicare Part B drugs and medical supplies provided from June 18, 
2021, to August 26, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please 
see the chart below.  
 
Date of Service Service Allowed Amount Amount You Owe 
6/18/2021 Laparoscopy $2,585.88 $325 
6/18/2021 Medicare Part B Drugs $13.09 $2.62 
7/29/2021 IV Therapy $383.40 $325 
7/29/2021 Medical Supplies $24.90 $4.98 
7/29/2021 Medicare Part B Drugs $1,898.42 $379.68 
8/6/2021 Medicare Part B Drugs $10,982.09 $2,196.42 
8/26/2021 Medicare Part B Drugs $10,982.09 $1,090.92 
 
The total amount you owe is: $4,324.63. 
 
You have been asked to pay the total amount of $4,324.63 for a laparoscopy, IV therapy, Medicare Part B 
drugs and medical supplies. A laparoscopy and IV therapy fall within the outpatient surgery and other medical 
services and provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. Medical supplies 
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 copayments for a laparoscopy and IV therapy and does not have to waive the 
coinsurance for Medicare Part B drugs and medical supplies provided from June 18, 2021, to August 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says this is not a covered 
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 Eliquis.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on August 26, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that plans are required to pay non-contract 
providers at the preferred provider rate when services are not available from preferred providers in the service 
area. You say that the in-network benefits should be honored, and the claim should be processed for pay The 
Plan denied your request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on August 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from June 4, 2021, to July 14, 2021. We also decided that the Plan does not have to waive the 
copayments for ambulance transportation services provided from June 16, 2021, to June 25, 2021. 
 
You asked the Plan to waive the copayment for the SNF services and ambulance transportation. You say that 
you feel that the charges are too high and the care service was sub-par. The Plan denied your request. The Plan 
says the enrollee was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $15 per day for days 1-20, $75 per day for days 21-44, and $0 per day for days 45-100 for each 
benefit period. 
 
The enrollees contract with the Plan clearly says that enrollees must pay a $125 copayment for each one-way 
ambulance trip, up to a yearly maximum of $500. 
 
Dates of Service Copayment Period Total 
June 4, 2021, to June 23, 2021 (1-20) $15/day $300 
June 24, 2021, to June 30, 2021 (21-27) $75/day $525 
July 1, 2021, to July 14, 2021 (28-40) $75/day $975 
Total:  $1,800 
 
The file shows that the enrollee was admitted to the skilled nursing facility from June 4, 2021, to July 14, 2021. 
The enrollee had been asked to pay $15 per day for days 1-20 and $75 per day for days 21-40 for the SNF 
services. The total for the benefit period is $1,800. The SNF services fall within the Skilled Nursing Facility 
(SNF) Care benefit category. The enrollee had also been asked to pay a $125 copayment for each ambulance 
transportation service, for a total of $375 ($125 copayment x 3 dates of service = $375). The ambulance 
transportation falls within the Ambulance Services 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 copayment for skilled nursing facility (SNF) services provided from June 4, 2021, to July 14, 
2021. We also decided that the Plan does not have to waive the copayments for ambulance transportation 
services provided from June 16, 2021, to June 25, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a chest x-ray provided on August 18, 2021. 
 
You asked the Plan to waive the copayment for a chest x-ray. You say that you were told that the insurance 
would cover all the claims related to COVID-19. You also say you have been healthy before this virus 
happened. The Plan denied your request. The Plan says that you have been charged the correct cost sharing 
amount. The Plan also says that COVID-19 related services are covered but that the coverage period has 
already ended. 
 
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 acknowledges copayments were waived for COVID-19 claims and 
related treatments. However, the plan has not provided any documentation detailing which services would 
qualify for the waiver or confirming when the waiver program ended. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair (E0240) and liners (A9999), provided on June 
19, 2021. 
 
You asked the Plan to pay for a shower chair and liners. You say that you need these items. The Plan denied 
your request. The Plan says these items do not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair (E0240) and liners (A9999), 
provided on June 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen equipment to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve oxygen equipment. You say that approval is needed to use an out-of-
network supplier. The Plan denied your request. The Plan says the denial of authorization for this item is 
correct, because this provider is out-of-network with the Plan and this item can be provided by an in-network 
supplier. 
 
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 
oxygen equipment to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that services were provided to the enrollee so 
the claim should be paid. The Plan denied your request. The Plan says both the referring and rendering 
providers are out-of-network providers with no prior authorization. Also, the services provided were 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 laboratory services provided on April 27, 2021, by 
an out-of-network (OON) provider.