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

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on May 24, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the transport was not related to the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on March 
31, 2022. 
 
You asked the Plan to pay for a digital, binaural hearing aid (V5261). You say that you did not realize you were 
required to go to a second rate hearing aid service. You also say that you are not second rate people, so you 
believe your service is covered by Medicare. The Plan denied your request. The Plan says they have partnered 
with a specific provider to provide your hearing exam and hearing aid benefit. The Plan also says that all 
appointments must be scheduled through this provider. The Plan also says that if you choose to schedule an 
appointment directly with a provider, your services will not be covered. 
 
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 plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you schedule your appointments through a specific Plan provider.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say that all appointments must be schedule through a 
Plan specific provider. The Plan rules also say that if you choose to schedule an appointment directly with a 
provider, your services will not be covered. The record shows that you scheduled your service directly with a 
provider, and not through the Plan specific provider. Based on this information, we decided that the Plan's rules 
for coverage of a digital, binaural hearing aid (V5261) have not been met. Therefore, we decided that the Plan 
does not have to pay for a digital, binaural hearing aid (V5261) provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telemedicine visit provided on July 20, 
2022. 
 
You asked the Plan to waive the copayment for telemedicine visit. You say that you are disputing the share 
cost. 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 $10 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $10 copayment for telemedicine visit. This item/service falls 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 the copayment for telemedicine visit provided on July 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation oncology services provided on May 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for radiation oncology services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 radiation oncology services provided on May 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was enrolled in hospice on the 
date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on June 13, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you are disputing the share 
cost. 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 $40 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $40 copayment for specialist office visit. This item/service falls 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 the copayment for specialist office visit provided on June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you appear to be more stable and improving with current treatment and do not 
require LTACH level care. You do not require services at the LTACH that are not already available at the 
current facility. 
 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99324), debridement of 
nails (11720), and trimming of skin lesions (11055) provided on March 30, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the podiatry services. You say that the enrollee's nursing home facility ordered a 
physician to provide care to residents. Treatment is provided in good faith and without discrimination with 
regards to insurance status. The Plan denied your request. The Plan says the services were non-urgent, and no 
authorization was obtained prior to rendering services to the enrollee. 
 
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 (99324), 
debridement of nails (11720), and trimming of skin lesions (11055) provided on March 30, 2022, by an out-of-
network (OON) provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 the enrollee does not require intensive rehabilitation and does not require frequent 
physiatry oversight. The enrollee's chronic medical issues are stable and have been routinely managed at an 
outpatient level. IRF admit is not medically necessary. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open right groin exploration with mesh removal and 
probable neurectomy. 
 
You asked the Plan to pre-approve an open right groin exploration with mesh removal and probable 
neurectomy. You say that the service is medically necessary. The Plan denied your request. The Plan says this 
service is not medically necessary. 
 
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 open right groin exploration with 
mesh removal and probable neurectomy. Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there has been no non-surgical 
interventions performed to address your pain such as a trial of pain medications or groin nerve blocks to 
confirm post herniorrhaphy neuralgia. You report that your pain has only been present for a few months, but 
the mesh was placed approximately 23 years ago. Open right groin explorative surgery would not be 
considered standard of care without first performing a trial of more conservative treatment and diagnostics 
testing.  
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 open right groin exploration with mesh removal and probable neurectomy 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an open right groin 
exploration with mesh removal and probable neurectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pain injections provided on June 28, 2022, 
to July 5, 2022. 
 
You asked the Plan to waive the copayment for pain injection. You say that you are disputing the share cost 
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 $190 
copayment for outpatient hospital observation. There were two pain injections, resulting in a total copayment 
amount of $380. 
 
You have been asked to pay $190 copayment for each pain injection. This item/service falls within the 
outpatient hospital observation 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 
pain injections provided on June 28, 2022, to July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on July 18, 2022. 
 
You asked the Plan to waive the copayment for an eye exam. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for in-network vision care/specialist's office.  
 
You have been asked to pay a $30 copayment for an eye exam. This item/service falls within the in-network 
vision care/specialist's office benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eye exam 
provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 22, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the home health services. You say that the services were rendered to the enrollee 
while in the nursing facility. The Plan denied your request. The Plan says the services were rendered to the 
enrollee while in the nursing facility. 
 
 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 home health services provided on May 22, 2022, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services provided on February 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that you were unaware that you were an 
OON provider, and it was necessary to see the enrollee. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved 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. 
 
  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 ophthalmological services provided on 
February 16, 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 repair/modification of a hearing aid (V5014) and hearing 
aid check (92592) provided on June 16, 2022. 
 
You asked the Plan to pay for the repair/modification of a hearing aid and hearing aid check. You say that you 
thought this was a follow-up, and you were not advised that you would be billed. You also say if you had 
known you would be billed, you would not have gone. The Plan denied your request. The Plan says these 
services are specifically excluded from coverage. 
 
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 plans coverage rules apply in this case. The Plan does not pay 
for the repair of hearing aids and related services. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the repair/modification of a hearing aid and hearing aid check have not been met. Therefore, we 
decided that the Plan does not have to pay for the repair/modification of a hearing aid (V5014) and hearing aid 
check (92592) provided on June 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to still be unstable and requires additional short term acute care 
services that can be safely administered at the current facility until more stable and appropriate for a lower 
level of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 31, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services provided on May 31, 2022, by 
an OON provider.