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

 
We decided that the Plan does not have to pay for home visit provided on March 9, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 home visit at issue in this appeal. The Plan did not pre-approve the 
home visit at issue. We found no exception that would require the Plan to pay for the home visit. Therefore, we 
decided that the Plan does not have to pay for home visit provided on March 9, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam and eye refraction provided on March 31, 
2022. 
 
You asked the Plan to pay for the eye exam and eye refraction. The Plan denied your request. The Plan says 
you are responsible for a $25 copay for each visit to a specialist. The Plan also says that the eye refraction will 
remain denied due to it not being a covered benefit when it is being performed for medical reasons. 
 
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. The Plan covers these services when the eye refraction is performed during a routine exam. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnosis of presence of intraocular lens. You are responsible for a $25 copay for the specialist visit. Based on 
this information, we decided that the Plan's rules for coverage of the eye exam and eye refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the eye exam and eye refraction provided on 
March 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on March 
2, 2022. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that this should not have a 
coinsurance charge as it is a preventative injection. 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug is $1251 resulting in a 
coinsurance amount of $250.20 ($1251 x 20% = $250.20) 
 
You have been asked to pay a $250.20 coinsurance for a denosumab injection. A denosumab injection 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 a denosumab injection provided on March 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service March 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair options and accessories. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requests do not serve a primary medical need. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The file shows that an adjustable back rest, push handles, privacy flap, and brake lock extension are not 
covered as they do not serve a purpose that is primarily medical in nature. The approved wheelchair includes 
casters. The extra casters requested serve the same purpose as the included casters. Based on this information, 
we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does 
not have to pre-approve wheelchair options and accessories.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy performed on 
March 28, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that your doctor ordered the 
procedure and you do not agree with the cost share. 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 $225 
copayment for each outpatient hospital facility visit.  
 
The records show that your procedure was ordered due to concerns of abdominal pain and a history of polyps. 
For this reason, the procedure is considered diagnostic. Therefore, you have been asked to pay a $225 
copayment for the colonoscopy. The colonoscopy falls within the Outpatient Surgery, Including Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 diagnostic colonoscopy performed on March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an intense multidisciplinary team is essential to 
identifying and establishing a functional platform for the enrollee to recover. Without IRF services the 
enrollee's health will be at risk. The Plan denied your request. The Plan says the documentation provided does 
not show that the enrollee is able to take part in 3 hours of therapy 5 days per week because they are not able to 
stay awake to work with therapy, the enrollee also is not expected to improve a lot in a reasonable time because 
they have already been to an IRF after their stroke and the enrollee still has a large deficit in strength, 
endurance, and performance. The services the enrollee needs can be provided safely in other settings like a 
skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for kidney stone and acute renal insufficiency. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam, eye refraction, and office visit provided on 
March 23, 2022, and April 7, 2022. 
 
You asked the Plan to pay for the eye exam, eye refraction, and office visit. The Plan denied your request. The 
Plan says you are responsible for a $25 copay for each visit to a specialist. The Plan also says that the eye 
refraction will remain denied due to it not being a covered benefit when it is being performed for medical 
reasons. 
 
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. The Plan covers these services when the eye refraction is performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnosis of combined forms of age-related cataract, bilateral. You are responsible for a $25 copay for the 
specialist visits. Based on this information, we decided that the Plan's rules for coverage of the eye exam, eye 
refraction, and office visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
eye exam, eye refraction, and office visit provided on March 23, 2022, and April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayments for specialist office visits provided 
from February 22, 2022, to April 18, 2022. 
 
You asked the Plan to waive or reduce the copayments for the specialist visits. You say that the provider you 
saw was only a nurse practitioner and your copayment should not be $40. 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 $40 
copayment for each specialist office visit.  
 
The file shows that you had a total of 3 specialist visits from February 22, 2022, to April 18, 2022. Please note 
that the copayments apply to the level of care received, not a specific provider. Therefore, you have been asked 
to pay a $40 copayment for each of the specialist visits, for a total of $120. The specialist visits fall within the 
Physician/Practitioner Services, Including Doctor's 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 or reduce the copayments for specialist office visits provided from February 22, 2022, to April 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for rest home visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 rest home visit at issue in this appeal. The Plan did not pre-approve the 
rest home visit at issue. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for rest home visit provided on March 9, 2022, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
October 12, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that this was a true 
emergency and the cost should be covered. 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 $250 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
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 transportation provided on October 12, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on March 23, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
amount of the copay and would like the plan to reconsider. The Plan denied your request. The Plan says the 
cost-sharing you are being charged is 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 $120 
copayment for each emergency room visit. Emergency care refers to services that are: furnished by a provider 
qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition. 
 
You have been asked to pay a $120 copayment for emergency room services. Emergency room services 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 
room services on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with power tilt. 
 
You asked the Plan to pre-approve a group three power wheelchair with power tilt. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested device. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair with power options are 
covered only for certain indications. 
 
Review of the file shows that the enrollee has no current or past pressure skin issues and no history of skin flap 
surgery. The enrollee can perform an effective pressure relief by standing up, can ambulate 15 feet, and has 
normal gait. The enrollee is not documented to utilize intermittent catheterization for bladder management. The 
enrollee does not have a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree 
flexion at the knee. This means that the requested power wheelchair with power tilt exceeds the enrollees 
needs. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair with 
power tilt.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies coded as T4528, T4535 and 
T4541. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have been getting these supplies for 
years and you do not understand why they are being denied now. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies coded as 
T4528, T4535 and T4541.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve SI RFA. You say that your chronic pain is affecting life function and daily 
activities. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this is not supported by research and is not covered. 
 
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 SI RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational procedure due to the wide variation of 
efficacy reported in the peer-reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on March 31, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mental health services. You say that the providers website says they are an 
in-network provider. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and the service rendered was 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 the mental health services provided on March 31, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair component or accessory, a battery (K0108) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a battery for your power wheelchair. You say that you need this battery for 
your car, as it is starting to go out. The Plan denied your request. The Plan says your records received do not 
indicate that you have an emergent or urgent medical condition or need specialized service(s) that are not 
available in the network. There are in-network provider(s) within a reasonable distance from your location that 
can provide this service or item. 
 
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 
a wheelchair component or accessory, a battery (K0108) to be provided by an out-of-network (OON) provider.