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

 
We decided that the Plan does not have to pay for repair of blepharoptosis (procedure codes 67900, 15769, 
15004, 67999, 21899) provided to the enrollee on March 3, 2022. 
 
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 the records do not show disabling symptoms that have failed conservative 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the enrollee had debilitating symptoms from her condition. 
The enrollee had incomplete paralysis of the right facial nerve, with right-sided facial paralysis resulting in 
hemifacial spasm. The enrollee went through PT, electrostimulation, acupuncture, and rest. It was 4 months 
until there was some improvement. The exam documented no brow movement, a flat nasolabial fold with smile, asymmetry of the lateral gutter with smile, and dimpling/hypertonic mentalis with smile. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for repair of blepharoptosis (procedure codes 67900, 15769, 15004, 67999, 21899) provided to the 
enrollee on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on June 17, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were not aware the injection 
cost more than previous injections received. You say that you contacted the provider and informed you they 
billed with the incorrect code. 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 20% 
coinsurance for Medicare covered Part B drugs and other Medicare covered items.  
 
You have been asked to pay a coinsurance of $548.52, which is 20% of the allowed amount for an injection 
($2,742.60 allowed x 20% = $548.52). This item/service falls within the Medicare Part B prescription drugs 
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 injection provided on June 
17, 2022.  Your complaint about not being informed of the cost for the injection 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
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 Ondansetron.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from April 25, 
2022, to May 4, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you state you were not in the 
ICU and do not understand this $200 copayment. 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 $700 
copayment for inpatient hospital services.  
 
You have been asked to pay a $200 copayment, which is less than the listed $700 for an inpatient stay. This 
item/service falls within the inpatient hospital 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 an inpatient stay provided from April 25, 2022, 
to May 4, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 10, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says the member was on hospice on the date of 
service, so either hospice or Original Medicare is responsible for this bill. The patient did not revoke hospice 
until November 12, 2021. 
 
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 medical services provided on November 10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
11, 2022, to May 12, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you cannot afford this 
copayment. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan.  Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit 
provided on May 11, 2022, to May 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on November 1, 2021 to 
November 4, 2021. 
 
You asked the Plan to pay for the inpatient hospital care. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the billed DRG is not supported in the records.  
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 DRG 915. 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 hospital care. Our reviewer says that the records do not support the 
billed DRG. Our physician reviewer found review has determined that the records did not support DRG 915. 
DRG 916 was the appropriate DRG for the hospitalization.  
 
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 care provided on November 1, 2021 to November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on May 11, 
2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you feel this bill is incorrect 
and that this was just a test. You would like your copayment back. 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 $30 
copayment for other outpatient diagnostic tests. 
 
You have been asked to pay a $30 copayment for an electrocardiogram. This item/service falls within the other 
outpatient diagnostic tests 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. You have been asked to pay $15.06, which is less than the original copayment of $30 for 
an electrocardiogram. Therefore, we decided that the Plan does not have to waive the copayment for an 
electrocardiogram provided on May 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 29, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are unable to afford the 
bill because you have other bills you are responsible for from your accident. 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on April 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 29, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are unable to afford the 
bill because you have other bills you are responsible for from your accident. 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care visit provided on May 25, 
2022. 
 
You asked the Plan to waive the copayment for a primary care visit. You say that you were informed by a 
member from the plan and your primary cares office that you would not have a copayment for your wellness 
check. You say that you are now receiving a bill for a $10 copayment. 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 $10 
copayment for physician/practitioner service. 
 
You have been asked to pay a $10 copayment for a primary care visit. This item/service falls within the 
physician/practitioner service 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 primary 
care visit provided on May 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 20, 2022, to April 18, 2022. 
 
You asked the Plan to pay for SNF care. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee was noted to be a custodial resident during these dates. 
 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that the enrollee required assessment by a 
professional nurse; however, there is no evidence that daily skilled nursing was provided or required and no 
skilled therapy services were provided thus daily skilled nursing on an inpatient basis in a skilled nursing 
facility was not medically necessary from March 20, 2022, to April 18, 2022. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from March 20, 2022, to April 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed for code 83789 for date of service 
March 24, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed for code 83789 for date of service March 24, 2022.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for COVID-19 testing kits purchased on May 16, 2022. 
 
You asked the Plan to pay for the COVID-19 testing kits. You say that you were told by the health plan the 
COVID-19 test kits would be reimbursed. The Plan denied your request. The Plan says that only tests 
performed by a lab or provider are covered. Home test kits are not eligible for reimbursement. 
 
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 rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing 
information. 
 
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 did not provide the IRE with a copy of the policy used to make the 
coverage determination. The information used to make the coverage determination is not included in the 
Evidence of Coverage. The call logs provided to the IRE by the plan show the enrollee was given ambiguous 
information. Therefore, we decided that the Plan has to pay for COVID-19 testing kits purchased on May 16, 
2022.  
 
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 SNF services are medically necessary. The Plan 
denied your request. The Plan says 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found although further rehabilitation services would be appropriate to improve function, as 
a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled 
nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care visit provided on May 16, 
2022. 
 
You asked the Plan to waive the copayment for a primary care visit. You say that you should not have a 
copayment for this visit. 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 $10 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for a primary care visit. This item/service 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 primary care visit provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that the Plan should pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 25, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) 
provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injections (CPT code(s): 64484RT 
and 64484LT). 
 
You asked the Plan to pre-approve the injections. You say that the services are medically necessary. The Plan 
denied your request. The Plan says medical studies do not show this procedure works better when done for 
more than one level. 
 
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 injections. Our physician reviewer 
found the request exceeds the utilization criteria of the LCD. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the epidural steroid injections (CPT code(s): 64484RT and 64484LT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal adjustment (D9951 x2) provided on June 2, 
2022. 
 
You asked the Plan to pay for an occlusal adjustment (D9951 x2). You say that you were unaware the dental 
procedure wasn't covered. You say that the dental office told you they checked and the procedure would be 
covered. The Plan denied your request. The Plan says there is no coverage for an occlusal adjustment (D9951). 
 
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 an 
occlusal adjustment (D9951 x2) provided on June 2, 2022.