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

We decided that the Plan does not have to waive the copayment for emergency care provided from April 1, 2021, to April 2, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you cannot afford 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 $50 copayment for emergency care. 

You have been asked to pay a $50 copayment for emergency care. Emergency care 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 emergency care provided from April 1, 2021, to April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) related services provided
on January 1, 2021 to January 31, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the end-stage renal disease (ESRD) related services. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a
covered benefit.

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 end-stage renal disease (ESRD) related
services provided on January 1, 2021 to January 31, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for fitting of contact lens provided on April 5, 2021. 
 
You asked the Plan to pay for fitting of contact lens. The Plan denied your request. The Plan says contact lens 
fitting is not covered by Medicare. 
 
Medicare generally does not cover routine vision services. Medicare does not pay for eye exams for the 
purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. 
 
We looked at the file and the Medicare rules. Medicare does not pay for eye exams for the purpose of 
prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Therefore, we decided 
that the Plan does not have to pay for prescription of optical and physical characteristics of and fitting of 
contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia (92310) 
provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for vision services provided on July 12, 2021. 
 
You asked the Plan to pay for vision services. The Plan denied your request. The Plan says you have exhausted 
your supplemental eyewear benefit for 2021.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and 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 that you have exhausted your vision benefit for 2021. 
Based on this information, we decided that the Plan's rules for coverage of vision services have not been met. 
Therefore, we decided that the Plan does not have to pay for vision services provided on July 12, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member's medical management and
rehabilitation needs require inpatient rehabilitation. The Plan denied your request. The Plan says that the
enrollee can safely receive the services she needs in other settings.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for coronary artery
bypass grafting. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation
needs. The patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a
need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cardiac magnetic resonance imaging (MRI) you had at an outpatient hospital facility on June 15, 2021.

You asked the Plan to reduce the copayment for the cardiac MRI. You say that you called to schedule this MRI at the stand-alone MRI center where you have gone before. You were told that this MRI could only be done at the hospital. You said that the typical copayment for an MRI is $180, but you have been asked to pay $275. You said that since you had no choice but to get this test at a hospital, you should not have to pay the higher copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $275 copayment for advanced imaging services at an outpatient hospital.

You have been asked to pay a $275 copayment for the cardiac MRI. This copayment applies regardless of the reason why you had this test at the hospital. 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 cardiac magnetic resonance imaging (MRI) you had at an outpatient hospital facility on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus vaccine (90715, 90472) provided June 11, 2021.

You asked the Plan to pay for the tetanus vaccine. You say that this service should be covered. The Plan denied your request. The Plan says this vaccination is not covered under the Part B medical benefit unless it is the result of an injury.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus vaccine (90715, 90472) provided June 11, 2021.

Benefits for the tetanus vaccine 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (22899, C9752, C9753).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is not covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to reduce the cost sharing for the duplex scans you had on November 19, 2020, 
and November 25, 2020. 
 
You asked the Plan to reduce the cost sharing for the duplex scans. You say that you believe you should only 
pay a $20 copayment for ultrasounds. The Plan denied your request. The Plan says that you were charged 20% 
coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $20 copayment for ultrasounds.  
 
The Plan says you must pay 20% coinsurance for the duplex scans because it is considered a diagnostic test.  
However, according to the National Library of Medicine at the www.medlineplus.gov website, the definition of 
the duplex scan is an ultrasound to test to see how blood moves through your arteries and veins.  So, this is 
clearly an ultrasound procedure. Based on the Plan contract, you cannot be asked to pay more than a $20 
copayment for the duplex scans. Therefore, we decided that the Plan has to reduce the cost sharing for the 
duplex scans you had on November 19, 2020, and November 25, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on May 11, 2021. 
 
You asked the Plan to reimburse you for hearing aids. You say that by negotiating with this provider you were 
able to save the Plan almost $200. The Plan denied your request. The Plan says you do not have coverage for 
hearing aid with a non-participating provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid 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 that the hearing aids were not provided by the Plan?s 
hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for prescription of optical and physical characteristics of and 
fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia 
(92310) provided on May 27, 2021. 
 
You asked the Plan to pay for prescription of optical and physical characteristics of and fitting of contact lens. 
The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
Medicare generally does not cover routine vision services. Medicare does not pay for eye exams for the 
purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. 
 We looked at the file and the Medicare rules. Medicare does not pay for eye exams for the purpose of 
prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. 
 
Therefore, we decided that the Plan does not have to pay for prescription of optical and physical characteristics 
of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for 
aphakia (92310) provided on May 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient hand surgery you had at an 
outpatient hospital facility on February 1, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hand surgery. You say that you were told by 
several people at the hospital that you would not have a copayment. The Plan denied your request. The Plan 
says you were charged this copayment 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 $300 
copayment for outpatient surgery.  
 
You have been asked to pay a $300 copayment for the outpatient hand surgery. The outpatient hand surgery 
falls within the outpatient surgery 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 
the outpatient hand surgery you had at an outpatient hospital facility on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor.

You asked the Plan to pre-approve a Dexcom device. You say that the requested item is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for continuous glucose monitors have not been
met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Dexcom
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom
continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Pembrolizumab injections you 
received from May 2, 2021, to May 18, 2021. 
 
You asked the Plan to waive the coinsurance for the Pembrolizumab injections. You say that you do not agree 
with this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 
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 chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Pembrolizumab injections. The Pembrolizumab injections 
fall within the chemotherapy drugs and other Part B 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 the Pembrolizumab injections you received from May 2, 
2021, to May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services provided to the enrollee on February 10,
2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Current Procedural Terminology (CPT) code 97530 - GO - CO - KX (4 units) remains
not supported. This service represents therapeutic activities, direct (one-on-one) patient contact (use of dynamic
activities to improve functional performance), each 15 minutes. These services were provided by an
occupational therapist assistant. For Medicare claims, this service should be coded as G0158 therefore, the
billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for
additional information.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes.

In this case, this claim cannot be paid as billed as there is a more appropriate code that should be used when
billing this service. Medicare rules for coverage of this service have not been met. Therefore, we decided that
the Plan does not have to pay for therapeutic services provided to the enrollee on February 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on October 20, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 lab services provided to the enrollee on October 
20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Accu-Chek test strips (A4253). 
 
You asked the Plan to pre-approve the Accu-Chek test strips. You say that the test strips are medically 
necessary. The Plan denied your request. The Plan says only preferred brands of diabetic test strips are covered.  
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The records provided do not show any reason the preferred brand 
would be unsafe or ineffective for the enrollee. Based on this information, we decided that Medicare rules for 
coverage of the Accu-Chek test strips have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Accu-Chek test strips (A4253).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0748).

You asked the Plan to pre-approve an osteogenesis stimulator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.

The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 

In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0748).