Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the eyewear purchased on December 21, 
2021. 
 
You asked the Plan to provide reimbursement for the eyewear. You say that you feel that this was incorrectly 
denied. The Plan denied your request. The Plan says this was correctly denied as routine vision must be 
received from VSP network providers. 
 
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 provided by a VSP network provider. 
 We looked at the file and the Plan's rules. You received these services from a provider that was not within the 
VSP network. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not 
been met. Therefore, we decided that the Plan does not have to provide reimbursement for the eyewear 
purchased on December 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve forty-eight (48) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
additional transportation trips because you have gastritis, and you need to see your doctor regularly. The Plan 
denied your request. The Plan says you have exhausted the maximum benefit of 48 one-way trips per year. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve forty-eight (48) additional routine transportation trips 
(A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows that the services were not performed for a hospital inpatient. Therefore, we decided that the Plan does 
not have to pay for the laboratory services rendered on January 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on August 22, 2021 to 
September 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We looked at the file and Medicare rules. There is no documentation to support that the services meet the 
criteria for coverage. 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 pay for the home health services 
rendered on August 22, 2021 to September 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services provided to the enrollee 
on January 13, 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 the services should be billed to Original Medicare. 
 
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 ambulance transportation services provided to the enrollee on 
January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology examination of tissue using a microscope, 
intermediate complexity (CPT code 88305) provided on September 10, 2021. 
 
You asked the Plan to pay for the pathology examination. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the pathology examination have not been met. The service billed, 
CPT 88305, has been completed on a Biopsy, prostate; needle or punch, single or multiple, any approach, CPT 
55700. This Prostrate Biopsy was rendered by the Physician that referred the Plan's member to you and per the 
guidelines the CPT code used on your claim is incorrect for this situation. If the provider determines that a 
billing error occurred during the initial submission of the denied claim, the plan will accept a submission of a 
corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for 
the pathology examination of tissue using a microscope, intermediate complexity (CPT code 88305) provided 
on September 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for INR monitoring services provided by an 
out-of-network (OON) provider on November 5, 2021. 
 
You asked the Plan to waive the coinsurance for the OON INR monitoring. You say that the test site changed 
without permission. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for out-of-network diagnostic procedures and tests.  
 
The file shows that the Plan determined the provider is an out-of-network provider. Therefore, you have been 
asked to pay $40.85, which is 50% of the allowed amount for the OON INR monitoring ($81.70 allowed 
amount x 50% coinsurance = $40.85). The OON INR monitoring falls 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 INR monitoring services provided by an out-of-network (OON) provider on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room (ER) visit and 
hospital observation care provided on March 17, 2022. 
 
You asked the Plan to waive the copayments for the ER visit and observation care. You say that you should not 
be charged for having to return to the hospital due to false test results. 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 $90 
copayment for each emergency room visit. 
 
Your contract with the Plan also clearly says that you must pay a $350 copayment for each outpatient hospital 
observation visit. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. You have also been asked to pay $260 for the observation care, which is less than the $350 
copayment. The observation care falls within the Outpatient Hospital Observation benefit category. The total 
for the services is $350. 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 an emergency room (ER) visit 
and hospital observation care provided on March 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on March 10, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you had a double mastectomy and 
would like the ultrasound covered as if it were a mammogram. 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 $50 
copayment for each standard X-ray and ultrasound.  
 
You have been asked to pay a $50 copayment for the ultrasound. The ultrasound falls 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 copayment for a breast ultrasound provided on March 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for INR monitoring services provided by an 
out-of-network (OON) provider on December 3, 2021. 
 
You asked the Plan to waive the coinsurance for the OON INR monitoring. You say that the test site changed 
without permission. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for out-of-network diagnostic procedures and tests.  
 
The file shows that the Plan determined the provider is out-of-network. Therefore, you have been asked to pay 
$40.85, which is 50% of the allowed amount for the OON INR monitoring ($81.70 allowed amount x 50% 
coinsurance = $40.85). The OON INR monitoring falls 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 INR 
monitoring services provided by an out-of-network (OON) provider on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D assay rendered on June 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the Vitamin D assay rendered on June 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 services are not medically necessary. Our physician reviewer found the enrollee has age-related 
osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drug, 
zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; 
therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 26, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were very sick and the doctor 
did not help you. 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 $45 
copayment for specialist visits.  
 
You have been asked to pay a $45 copayment for the office visit. The office visit 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 a specialist office visit provided on February 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a specialist office visit and 
collagenase injections provided on December 20, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the office visit and injections. You say that the 
services should be fully covered since you had authorization. The Plan denied your request. The Plan says the 
correct copayment and coinsurance were applied. 
 
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 visit. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $1,314.51 ($6,572.56 allowed amount x 20% coinsurance = $1,314.51) and $725.25 ($3,626.24 allowed 
amount x 20% coinsurance = $725.25) for the injections. The injections fall within the Medicare Part B 
Prescription Drugs benefit category. The total for the services is $2,079.76. 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 and coinsurance for a specialist office visit and collagenase injections provided on 
December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a commode chair provided on February 
25, 2022. 
 
You asked the Plan to waive the coinsurance for the commode chair. You say that the charges should be 
waived due to your COVID-19 diagnosis. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
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 durable medical equipment (DME).  
 The file shows that the Plan determined there were no active COVID-19 diagnosis codes used for the claim. 
Therefore, you have been asked to pay $10.44, which is 20% of the allowed amount for the commode chair 
($52.22 allowed amount x 20% coinsurance = $10.44). The commode chair falls within the Durable Medical 
Equipment (DME) and Related 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 a commode chair provided on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage 
Determination (LCD): Respiratory Assist Devices - L33800. The requested ventilator is being used in a bilevel 
positive airway pressure (BiPAP) mode. Provided records do not document that a BiPAP device (E0471) with 
average volume assured pressure support (AVAPS) would not meet the enrollee's ventilatory needs.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services rendered from February 8, 
2022 to February 22, 2022. 
 
You asked the Plan to pay for these services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the services were not medically necessary. 
 
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 pay for these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the records show that you required daily 
skilled nursing services, as you were receiving daily skilled wound care for a stage three sacral ulcer and 
frequent monitoring of your electrolytes and blood pressure. You were also receiving intravenous (IV) 
antibiotics. You had documented functional impairments in both mobility and self care and required daily 
skilled therapy services. As a practical matter, you required the necessary services on an inpatient basis at the 
SNF level of care for the dates of service at issue. 
 
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 been met. The Plan must continue coverage for the SNF 
skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or 
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for the skilled 
nursing facility (SNF) services rendered from February 8, 2022 to February 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve Dexcom CGM supplies. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of Dexcom 
CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom 
continuous glucose monitor (CGM) supplies.