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

 
We decided that the Plan does not have to pay for the refraction provided on March 17, 2021. 
 
You asked the Plan to pay for the refraction. You say that you were told an eye exam included a refraction and 
you should only owe a total of $50. The Plan denied your request. The Plan says the claim processed correctly. 
 
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.  
 
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 refraction have not been met. Specifically, an eye refraction is not a covered benefit. Therefore, 
we decided that the Plan does not have to pay for the refraction provided on March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 9, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you received the services in a 
freestanding facility and disagree with the charges. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct 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 $0 
copayment for ultrasounds provided in a primary care providers office, specialists office, urgent care center, or 
a stand-alone imaging center and a $50 copayment when provided in an outpatient hospital facility.  
 
The record shows that you received an ultrasound at an outpatient hospital facility on July 9, 2021. Therefore, 
you are responsible to pay the $50 copayment.  
 You have been asked to pay a $50 copayment for an ultrasound. An 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 an ultrasound provided on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that these orthotics are medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 12, 
2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare says screening panels/testing with no relation to a medical diagnosis of disease 
are not a benefit. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found these services are not authorized because molecular genetic screening testing is not a Medicare benefit 
for the diagnoses as listed on the claim and are done for screening purposes. This was not COVID screening testing. The review has determined that the services at issue in this case were not medically reasonable or 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310), provided on April 13, 2021. 
 
You asked the Plan to pay for a dental consultation. You say that you needed the service. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, the service is not listed in the Plan's benefit chart. This 
means the service is not covered.  
 
  
 
Therefore, we decided that the Plan does not have to pay for a dental consultation (D9310), provided on April 
13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for dialysis services provided from May 2, 2020, to May 29, 2020. 
 
You asked the Plan to pay for dialysis. You say that you have been billing claims in a timely manner. The Plan 
denied your request. The Plan says that the denial of payment for these services is correct. 
 
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 rules say that claims for services furnished on or after January 1, 2010, must be filed no later 
than one calendar year after the date of service. 
 
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 initially denied payment for this claim because the timely filing period 
had expired. The Plan did not provide any evidence to support that this claim was not submitted within the 
timely filing limit. Without this information, we cannot determine whether the claim at issue in this case was 
submitted within the timely filing limit. The Plan provided no other rationale to support a denial of payment for 
this claim. Therefore, the Plan has not shown that its decision to deny payment for these services is correct or 
justified according to Medicare rules. Therefore, we decided that the Plan has to pay for dialysis services 
provided from May 2, 2020, to May 29, 2020.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray services provided on May 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the X-ray services. You say that you were unaware this required prior 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained for these 
services obtained by an OON 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 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 X-ray services provided on May 10, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for stereotactic radiation treatment coded as 77432 provided on 
June 1, 2021. 
 
You asked the Plan to pay for stereotactic radiation treatment. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says separate 
reimbursement is not allowed for this specific code. 
 
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 code 77432 is stereotactic radiation treatment management of 
cranial lesion(s) (complete course of treatment consisting of 1 session). 
 
We find that CPT code 77432 is not supported in the medical record. In this case, we have confirmed that code 
77432 is a column II code to column I code 61798. The modifier indicator for these pairing is 0 indicating that 
CPT code 77432 cannot be paid regardless of what modifier is used. Therefore, we decided that the Plan does 
not have to pay for stereotactic radiation treatment coded as 77432 provided on June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator (E1399). 
 
You asked the Plan to pay for a portable oxygen concentrator. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item as owned. 
 
The Plan follows Medicare Rules. The rules say that for oxygen and oxygen equipment, contractors pay a 
monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, 
contents and supplies. Payment is not made for purchases of this type of equipment. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 20, 30.6. 
 
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 portable oxygen concentrator have not been met. Specifically, the Plan only 
allows you to rent this item. Therefore, we decided that the Plan does not have to pay for a portable oxygen 
concentrator (E1399).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from February 11, 2021, 
through February 14, 2021. 
 
You asked the Plan to pay for inpatient hospital care. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated tothe terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 8, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital 
care provided from February 11, 2021, through February 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on November 2, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 $200 
copayment for CT scans.  
 
You have been asked to pay the allowed amount of $152.37, which is less than the $200 copayment for a CT 
scan. A CT scan 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 CT scan provided on 
November 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from May 17, 2021, to May 19, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not 
have to pay this copayment because the hospital failed to test you for COVID-19 even though you had all of 
the symptoms. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment per day for days 1-5 for inpatient hospital care.  
 
Records show that you were in the hospital for two days. You have been asked to pay a $300 copayment per 
day for the inpatient services, for a total of $600. This copayment applies regardless of your satisfaction with the care received. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services 
you received from May 17, 2021, to May 19, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the enrollee does meet the health condition for this stay. The Plan states the 
enrollee does not need skilled therapy services five (5) days a week and they do not need daily skilled nursing 
care. The Plan states the enrollee can receive the care they need in another setting, such as at home, in a long-
term care facility, or other outpatient setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary 
and reasonable treatment. This enrollee does require skilled therapy services, i.e., the specialized skill, 
knowledge and judgment of a qualified therapist are required to safely and effectively provide medically 
necessary and reasonable treatment. Daily skilled services are not required. This enrollee does not require the 
services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis 
appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided March 31, 2021. 
 
You asked the Plan to pay for the limited oral exam and intraoral x-ray. You say that your dentist says they 
were told the services would be covered and you cannot afford the cost of the services. The Plan denied your 
request. The Plan says the limited oral exam is not covered under your benefits and you have exceeded the 
frequency limit for the intraoral x-rays. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers one intraoral 
x-ray per calendar year.  
 
 We looked at the file and Medicare rules. The Plan provided documentation showing that an intraoral x-ray 
was covered on March 24, 2021. Based on this information, we decided that the Plan's frequency limit for 
coverage of the intraoral x-ray has been exceeded. Though the Plan offers dental benefits in excess of Medicare 
coverage, the limited oral exam is not among those covered by the Plan. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first 
radiographic image (D0220) provided March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from January 17, 2020, 
through January 21, 2020, billed with a secondary diagnosis code of metabolic encephalopathy. 
 
You asked the Plan to pay for the inpatient hospital care as billed. You say that the inpatient hospital services 
as billed are supported by the medical documentation. The Plan denied your request. The Plan says there is no 
evidence in the medical records provided that supports the billed secondary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, G93.41, defined as 
metabolic encephalopathy. 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 the inpatient 
hospital care as billed. Our reviewer says that the secondary diagnosis code billed of metabolic encephalopathy 
is not supported by the medical records. Our physician reviewer found the review indicates that the enrollee 
had an admission for Alzheimer's Disease. The documentation was inconsistent/unclear regarding a diagnosis 
of Metabolic Encephalopathy. Even though Metabolic Encephalopathy is documented on H&P, supporting 
medical record documentation was not found within the record. Member presented with after fall. Appeal letter 
noted documentation of metabolic encephalopathy, altered mental status, confusion and agitation. Member has 
history of dementia as documented by physician, per daughter dementia is worse and can't take care of herself. 
While member presentation warranted consideration of Metabolic encephalopathy there was no documentation 
to support a change in mental status beyond baseline that persisted beyond treatment in the emergency 
department and no documentation of potential cause. The review has determined that the medical records did 
not support the secondary diagnosis billed of G93.41 defined as metabolic encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from January 17, 2020, through January 21, 2020, billed with a 
secondary diagnosis code of metabolic encephalopathy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 18, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing genomic 
screening panels for suspected or documented cardiovascular disease. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare denies coverage for all cardiovascular risk assessment testing genomic screening panels for 
suspected or documented cardiovascular disease. Medicare only covers a lipid panel consisting of a total 
cholesterol, HDL cholesterol, and triglyceride every 5 years, as cardiovascular screening 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on March 18, 2021.