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

 
We decided that the Plan does not have to waive the copayment for drugs provided on May 19, 2022, to June 3, 
2022. 
 
You asked the Plan to waive the copayment for drugs. 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 20% 
coinsurance for Medicare Part B prescription drugs. For date of service May 19, 2022, the allowed amount of 
this drug total $12,829.80, resulting in a total coinsurance amount of $2,565.96. You are being asked to pay 
$474.04, which is less than 20% coinsurance of the allowed amount for the Part B drugs received on June 3, 
2022. The record shows your 2022 maximum out of pocket was met as of August 1, 2022. 
 
You have been asked to pay 20% coinsurance for drugs. This item/service falls within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for drugs provided on 
May 19, 2022, to June 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy provided on July 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient mental health services provided from April 11, 2022, to 
April 14, 2022. 
 
You asked the Plan to pay for the inpatient mental health services. You say that you were advised that the 
enrollee had 190 psychiatric days as of February 1, 2022. The Plan denied your request. The Plan says that the 
benefit of 190-days per lifetime has been exhausted prior to the dates of service in this case. 
 
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. Specifically, the file does not support that the 190-day benefit was exhausted 
prior to the dates of service in this case. Therefore, we decided that the Plan has to pay for the inpatient mental 
health services provided from April 11, 2022, to April 14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) provided on January 14, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for DME. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 durable medical equipment (DME) provided on 
January 14, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 17003 billed for date of service April 15, 
2022. 
 
You asked the Plan to pay for procedure code 17003. You say that the documentation submitted supports 
payment of this code. The Plan denied your request. The Plan says payment for code 17003 is bundled into 
payment for code 71770. 
 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 17003 
is a column II code to column I code 71770. 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 17003 billed for date of service April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on May 6, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it is the facilities responsibility to obtain 
prior authorization and service was rendered to the enrollee out of medical necessity. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no approved authorization. 
Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on May 6, 2022, 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on July 
17, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not pay a 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit 
provided on July 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulatory surgical center visit provided 
on June 21, 2022, to July 12, 2022. 
 
You asked the Plan to waive the copayment for ambulatory surgical center 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 $225 
copayment for outpatient surgery.  
 
You have been asked to pay $225 copayment for ambulatory surgical center visit. This item/service falls within 
the outpatient surgery 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 ambulatory 
surgical center visit provided on June 21, 2022, to July 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance response and treatment, no transport on July 7, 
2022. 
 
You asked the Plan to pay for an ambulance response and treatment, no transport. You say that you would like 
to request reconsideration of the denied claim. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for an ambulance response and treatment, no transport 
on July 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that only Lucentis and Eylea have specific approval for the 
enrollee's eye conditions. The Plan denied your request. The Plan says the enrollee has not tried and failed 
Avastin. 
 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 Eylea. Our physician reviewer found 
that the enrollee has moderate proliferative diabetic retinopathy. The Plan requires a trial of Avastin before they 
will approve the requested drug. There is no indication that the enrollee has tried and failed the required drug.  
There is no indication that the Plan's required drug would likely be less effective or likely have adverse effects 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided from June 1, 2022, to June 2, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you would like this denial to be 
reconsidered because there was a COVID-19 outbreak, which resulted in an extended stay for the enrollee, and 
you believe this should be covered by the enrollee's insurance. 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 $0 copayment each day for Medicare-covered days 1 to 20, a $188 copayment each day for 
Medicare-covered days 21 to 36, and a $0 copayment for additional Medicare-covered days, up to 100 days for 
Skilled Nursing Facility (SNF) Care.  
 The enrollee has been asked to pay a $188 copayment each day for Medicare-covered days 21 to 36 for the 
SNF care. This item/service falls within the Skilled Nursing Facility (SNF) Care 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 the skilled nursing facility (SNF) care provided from June 1, 
2022, to June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. The Plan denied your request. The Plan says the requested 
shower chair is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9502 billed for date of service February 25, 
2022 to March 3, 2022. 
 
You asked the Plan to pay for procedure code S9502. You say that this is a valid and payable code. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9502 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9502 billed for date of service February 25, 2022 to March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on April 29, 2022. 
 
You asked the Plan to pay for the domiciliary, rest home visit. You say that the providers rely on the assisted 
living facility staff to verify eligibility and obtain authorization from the patients insurance company. The Plan 
denied your request. The Plan says the services were not urgent or emergent and the services could have been 
rendered by a Plan participating 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 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on April 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (thyroid) test (81546) provided on June 3, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oncology (thyroid) test. You say that you would like this claim to be covered 
by the Plan. The Plan denied your request. The Plan says this service was rendered by a provider who is not a 
network provider with the Plan. The Plan also says that these services are not urgent or emergent, nor were they 
approved in advance. 
 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 oncology (thyroid) test (81546) provided on 
June 3, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an infusion provided from February 18, 
2022, March 18, 2022, and May 13, 2022. 
 
You asked the Plan to waive the coinsurance for an infusion. You say that you cannot afford this coinsurance. 
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% 
coinsurance for Medicare Part B drugs and supplies.  
 
You have been asked to pay a total $1,880 coinsurance for three infusions. This item/service falls within the 
Medicare Part B drugs 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 
an infusion provided from February 18, 2022, March 18, 2022, and May 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a telehealth service provided on July 28, 
2022. 
 
You asked the Plan to waive the coinsurance for a telehealth service. You say that you were charged for a 60 
minute sesson when you only had a 45 minute session. 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 20% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 20% coinsurance for a telehealth service. This item/service falls within the 
physician/practitioner services, including doctors 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 coinsurance for a telehealth service provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service February 10, 
2022. 
 
You asked the Plan to pay for procedure code S9338. You say that other claims for this member have been 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service February 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
07, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that this was due to covid 
and you should not have to pay a 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan.  Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit 
provided on June 07, 2022.