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

 
We decided that the Plan does not have to waive the coinsurance for laboratory services (80053, 80061, 81001, 
82043, 82306, 82570, 82607, 83036, 85025) rendered on June 9, 2021. 
 
You asked the Plan to waive the coinsurance for laboratory services. You say that you were sent an invoice 
from the provider for $0 and then received a second invoice later for $5.66 for this date of service. The Plan 
denied your request. The Plan says you were 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 10% 
coinsurance for Medicare-covered lab services.  
 
You have been asked to pay a $5.66 coinsurance, which is 10% of the allowed amount for laboratory services 
($56.45 allowed amount x 10% coinsurance = $5.66). Laboratory services 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 coinsurance 
for laboratory services (80053, 80061, 81001, 82043, 82306, 82570, 82607, 83036, 85025) rendered on June 9, 
2021.  
 
Your complaint about potentially being billed unnecessary bills 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (33340) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the device would reduce the risk of stroke as a 
result of non-valvular atrial fibrillation. The Plan denied your request. The Plan says that the member is 
suitable for long term anti-coagulation. 
 
The Plan must follow Medicare rules. Medicare rules say that the percutaneous transcatheter closure of the left 
atrial appendage with endocardial implant can be covered if NCD criteria is met. 
 
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 requested services are not considered medically reasonable and necessary in this case. The record indicates 
that the enrollee has non-valvular atrial fibrillation. The record indicates that the enrollee is successfully treated 
with Pradaxa. The record does not indicate that enrollee is unable to take oral anticoagulation. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 
 
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 the percutaneous transcatheter closure of the left atrial appendage with endocardial implant 
(33340) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brand specific over the counter (OTC) items. 
 
You asked the Plan to pre-approve brand specific OTC items. You say that if the Plan wants to give money to 
buy food or other supplies then it should not be limited to a specific type or brand. The Plan denied your 
request. The Plan says items outside of the Medicare approved list are not eligible to be purchased. 
 
The Plan contract clearly says that the allowance for OTC items is only for approved items. The OTC Savings 
Guide lists all the approved OTC items. Therefore, we decided that the Plan does not have to pre-approve other 
OTC items.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit securement package for a power wheelchair. 
 
You asked the Plan to pre-approve the package. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is meant for use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit securement package for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON cardiology consultation. You say that your condition is complicated, and you feel that the providers at the Clinic have the required expertise. The Plan denied your request. The Plan says your network has a tertiary, academic facility available who can provide the expert second opinion you require.
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 provider at issue in this case is not a network provider with the Plan. 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 OON cardiology consultation. Our reviewer says that the requested OON care is not shown to be reasonable and necessary in this case, as the Plan has a network provider available. Our physician reviewer found the enrollee has Class II congestive heart failure and a moderately depressed ejection fraction. His fatigue has not been thought to be due to this, but his ejection fraction is lower than prior to recent surgery. The fatigue has been extensively evaluated by his local physicians without a clear etiology being found. His primary physician is concerned it could possibly be related to paroxysmal atrial fibrillation and whether a radiofrequency ablation procedure might be helpful in this instance. The local cardiologists have not recommended this, but he continues to have chronic fatigue.
A second opinion at a tertiary medical center is a reasonable consideration in this patient to assess the fatigue and the possibility of cardiac causes. The Plan's center is a full-service tertiary medical facility which would have all the specialized tertiary services and providers including the cardiac services necessary (invasive electrophysiology, heart failure management, general cardiology) to assess a possible cardiac etiology of the fatigue and treat any of these possibly related cardiac conditions, similar to those at the Clinic. Therefore, there are no clear medical necessity reasons which would require referral to the non-contracted tertiary provider.
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 OON cardiology consultation have not been met. 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 the OON cardiology consultation. Therefore, we decided that the Plan does not have to pre-approve cardiology consultation to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you received 
on July 19, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that this service was part of your annual 
wellness exam, so there should not be 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 $20 
copayment for diagnostic procedures or tests.  
 
According to your Evidence of Coverage, an annual wellness exam is a visit to develop or update a 
personalized prevention plan based on your current health and risk factors. It does not say that labs or 
diagnostic tests are included as part of this exam. You have been asked to pay a $20 copayment for the ECG. The ECG falls within the diagnostic procedures or 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. Therefore, we decided that the Plan does not have to waive 
the copayment for the electrocardiogram (ECG) you received on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for an office visit provided to the enrollee on July 2, 2020.
You asked the Plan to pay this claim. You say that you are eligible to accept Medicare payment as an out of
network provider and these services should be covered by the Plan. The Plan denied your request. The Plan
says that you are excluded or debarred from participation in State and Federal healthcare programs. The QIC
upheld the Plans denial. After additional review of several cases from your office, we reopened the appeal.
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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules
for coverage of these services were met. The Plan did not provide documentation to show that you are excluded
from receiving Medicare reimbursement. The QIC performed a search of the List of Excluded Individuals
and/or Entities from the Office of Inspector General and did not find that you were on this list. Without specific
documentation from the Plan showing that you were excluded to receive Medicare reimbursement at the time
the services were provided, the denial cannot be substantiated. Therefore, we decided that the Plan has to pay
for an office visit provided to the enrollee on July 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation (A0080) provided on July 
2, 2021. 
 
You asked the Plan to pay for the non-emergency transportation. You say that you scheduled transportation 
with the Plan approved transportation provider, but no one ever showed up. The Plan denied your request. The 
Plan says this transportation was rendered by a non-approved transportation provider.  The Plan also says that they contacted the Plan approved transportation provider and were advised that no 
transportation services were scheduled for you on July 2, 2021. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers routine transportation when the services are provided by the Plan-approved 
transportation provider.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan?s rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for the non-emergency transportation (A0080) provided on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from June 1, 2021, to June 3, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel as though 
you were mistreated in the emergency room, so you should not have to pay this 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 $250 
copayment per day for days 1-3, and a $0 copayment per day for days 4 and up for inpatient hospital services.  
 
Records show that you were in the hospital for two days.  You were charged a $250 copayment per day for a total of $500. This copayment applies regardless of your satisfaction with the services received. 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 inpatient hospital services you received from June 1, 2021, to 
June 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network professional visit service provided to the
enrollee on October 9, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan
denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
The QIC overturned the Plans denial stating the services were shown to be necessary. The Plan requested a
reopen and stated that these services were not emergent and were not authorized.
The Plan is correct in this case. 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 an out of network professional visit service provided to the enrollee on October 9, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or 
skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter 
this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
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 pay for the nail debridement (11720) rendered by an out-of-network 
(OON) provider on April 29, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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. 
 
You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.  We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the nail debridement (11720) rendered by an out-of-network (OON) provider on  
April 29, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan for screening
purposes under coded as 71250.
You asked the Plan to pre-approve a CT scan for screening purposes. The Plan notes the provider should have
ordered code G0297 for a low dose CT scan which would have been approved. You say that this imaging is
medically necessary. The Plan denied your request. The Plan says Medicare does not cover the CT scan
ordered as a screening. The QIC overturned the Plans denial. The Plan requested a reopen and stated it was
confirmed that the provider submitted the wrong code for the intended service.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that CT scans are
covered only when they are medically necessary. In this case it was a situation of the wrong CT scan code
being submitted for service. The provider should have submitted the request for G0297 for a low dose CT scan,
which appears to have been the intended service. Therefore, we decided that the Plan does not have to pre-approve
a computed tomography (CT) scan for screening purposes under code 71250.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) (CPT Code 90471) and oster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for intramuscular use (90750) on July 31, 2020, from Rite Aid Pharmacy.
You asked the Plan to pay for the services. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered under the Plan and you do not have Part D coverage.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Vaccines covered under the Part D prescription drug benefit (e.g., zoster vaccine (shingles)) are NOT covered under the plan. Therefore, we decided that the Plan does not have to pay for immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) (CPT Code 90471) and oster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for intramuscular use (90750) on July 31, 2020, from the Pharmacy.
Benefits for the services 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 pre-approve contact lenses provided on April 24, 2020.
You asked the Plan to pre-approve the contact lenses. You say that you were not aware that you were required to wait exactly 24 months to order contact lenses again. You say that you also did not know when you ordered contact lenses in the year 2018. You say that you realized you were running short on daily lenses and decided to order them online, since you couldn't go to the store in person due to the COVID-19 virus. You say that even though you ordered the contact lenses online on April 24th, you didn't receive them for 2 weeks. The Plan denied your request. The Plan says the benefit for the vision wear reimbursement was exhausted on the date of service in dispute.
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 up to $100 toward the cost of eyewear or contact lenses once every 24 months.
We looked at the file and the Plan's rules. The records show that you were last provided reimbursement of $100 toward the cost of eyewear purchased on May 18, 2018. This means that 24 months had not yet passed when the eyewear in dispute was purchased. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve contact lenses provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care billed with a Health 
Insurance Prospective Payment System (HIPPS) code KGSD1 provided from February 1, 2020, to February 23, 
2020. 
 
You asked the Plan to pay for SNF care. You say that this is supported in the records. The Plan denied your 
request. The Plan says the billed HIPPS code cannot be verified because timely assessments were not 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that skilled nursing facilities (SNFs) must submit 
assessments according to an assessment schedule. This schedule must include performance of an initial 
Medicare assessment with an assessment reference date that is set for no later than the 8th day of posthospital SNF care, and such other interim payment assessments as the SNF determines are necessary to account for 
changes in patient care needs. Medicare pays a default rate for the Federal rate when a SNF fails to comply 
with the assessment schedule.  
 
We looked at the file and Medicare rules. The submitted medical records do not include assessments performed 
according to the Medicare assessment schedule. 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) care billed with a Health Insurance Prospective Payment System (HIPPS) code KGSD1 
provided from February 1, 2020, to February 23, 2020.