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

 
We decided that the Plan does not have to pay for the self-administered drugs provided on June 20, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like this decision to be 
reconsidered for coverage. The Plan denied your request. The Plan says self-administered drugs are not a 
covered benefit while under an outpatient hospital stay. 
 
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 pay for the self-administered drugs 
provided on June 20, 2022.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit, psychotherapy, and injection 
provided on March 4, 2022, by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit, psychotherapy, and injection. You say that you 
rely on facility staff to verify eligibility and obtain the authorization from the enrollee's insurance company. 
The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
 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 a domiciliary or rest home visit, psychotherapy, 
and injection provided on March 4, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence garments and supplies (A4520 Pull-on, 
A4520 Liners, A6250 Ointment, and A9286 Wipes). 
 
You asked the Plan to pre-approve incontinence garments and supplies. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says these items are not covered by Medicare or 
the Plan. 
 
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 garments and 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 
garments and supplies (A4520 Pull-on, A4520 Liners, A6250 Ointment, and A9286 Wipes).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that special 
supplemental benefits for the chronically ill is medically necessary. The Plan denied your request. The Plan 
says special supplemental benefits for the chronically ill is not medically necessary. Per the attestation 
submitted by the provider, the member does not have a need for intensive case management, is not a high risk 
for hospitalization with diagnosis of diabetes & chronic and disabling mental health conditions.  
The Plan contract covers special supplemental benefits for the chronically ill benefit. The Plan benefit says in 
order to be eligible to receive the benefit(s) you must be under care management and have one or more 
qualifying chronic condition. 
 
We looked at the file and the Plans rules. Based on this information, we decided that Medicare rules for 
coverage of special supplemental benefits for the chronically ill have not been met. Therefore, we decided that 
the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on March 
20, 2022, by an OON provider. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that you are appealing the denial 
of physician services rendered to the enrollee. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
 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 a subsequent nursing facility care visit provided 
on March 20, 2022, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
07, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that it was not your choice to 
go to a facility where you could not receive proper care. 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 $250 
copayment for ground ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ground 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 the 
ambulance services provided on March 07, 2022.
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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says this service does not meet the criteria for medical necessity or appropriateness because it 
is for a chronic condition. This service could safely be provided in an alternate setting or with an alternate 
method of treatment at a skilled nursing facility. 
 
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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service June 23, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on January 
28, 2022, to March 14, 2022. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you were not charged for 
these services until recently. 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 $117 
copayment for physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $117 copayment for the specialist services. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist) 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. The file shows the provider specialty is 
orthopedics. Per the EOC, there is a $39 copayment per visit. You had 3 visits, for a total of $117. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services provided on January 
28, 2022, to March 14, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for vascular services (procedure code 37238, 37239, 75820) provided to 
the enrollee on April 27, 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 that the records do not support the services billed. 
 
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, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 37238: 
 
Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision 
and interpretation and including angioplasty within the same vessel, when performed; initial vein 
 
CPT 37239: 
 
Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision 
and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List 
separately in addition to code for primary procedure) 
 
CPT 75820: 
 
Venography, extremity, unilateral, radiological supervision and interpretation 
 
We asked our coder 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 services Our 
reviewer found that the documentation supports that the codes in question were performed and satisfactorily 
documented in the procedural note.  There is satisfactory documentation of imaging of the right lower 
extremity venous outflow in the form of iliac venography. This is appropriately coded with 75820.  There is 
documentation that one stent was placed starting in the right common iliac vein and a second stent was placed 
starting in the right external iliac vein. These are considered 2 separate vessels and the documentation supports 
that there were two separate stents of different sizes. Therefore, use of code 37238 and the add-on code 37239 
was appropriate as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
vascular services (procedure code 37238, 37239, 75820) provided to the enrollee on April 27, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eye surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve eye surgery. You say that you need this surgery. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan and you can be treated by an in-network 
provider. 
 
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 
eye surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye medical examination and evaluation 
(92012) provided on February 11, 2022. 
 
You asked the Plan to waive the copayment for an eye medical examination and evaluation (92012). You say 
that you did not request vision service. You also say that there was no eye exam given. 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 $20 
copayment for each Medicare-covered eye examination to treat an eye condition.  
 
 
  You have been asked to pay a $20 copayment for an eye medical examination and evaluation (92012). This 
item/service falls within the Medicare-covered eye examination to treat an eye condition benefit category. The 
record shows that an eye examination was given. 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 eye medical examination and evaluation (92012) provided on February 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 8, 2022, to April 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. 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 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 psychotherapy provided on January 8, 2022, to 
April 30, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Aranesp for the enrollee. 
 
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your 
request. The Plan says that that there is no indication the preferred drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided any medical records to substantiate their denial. 
Therefore, we decided that the Plan has to pre-approve Aranesp for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services on November 16, 2020. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you want to appeal the amount 
being charged. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $45 copayment each Medicare-covered visit in an office or home setting. Covered services include 
diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or heel 
spurs). Routine foot care for members with certain medical conditions affecting the lower limbs. The provider 
billed in the amount of $70 and the allowed amount is $31.76. This is less than the copayment amount. 
Therefore, results in the total cost sharing amount of $31.76. 
 
 
 
 The enrollee has been asked to pay a $31.76 copayment, which is less than the copayment for podiatry services. 
This item/service falls within the Podiatry services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for podiatry services on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and knee x-rays 
provided on May 19, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visit and knee x-rays. You say that your 
primary care doctor's office was not open, and you felt it was an emergency. 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 $35 
copayment for physician specialist services.  
 
Your contract with the Plan also clearly says that you must pay a $10 copayment for x-rays performed by a 
provider other than your PCP. 
 You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
physician specialist services benefit category. You have also been asked to pay a $10 copayment for the x-rays. 
This item/service falls within the x-rays performed by a provider other than your PCP benefit category. The 
total for all services is $45. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for a specialist office visit and 
knee x-rays provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive hearing test provided on June 1, 2022, by 
an OON provider. 
 
You asked the Plan to pay for a comprehensive hearing test. You say that you were given an annual hearing test 
but the claim was denied. You say that your doctor says the service is needed to provide proper hearing care. 
The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 a comprehensive hearing test provided on June 1, 
2022, by an OON provider.