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

 
We decided that the Plan has to pay for the medication assisted treatment (G2067) provided on December 5, 
2022. 
 
You asked the Plan to pay for the medication assisted treatment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The facility where the provider rendered the services is enrolled with Medicare 
as an OTP. The OTP is the billing provider and is Substance Abuse and Mental Health Services Administration 
(SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the 
OTP meets the Medicare coverage criteria. Therefore, we decided that the Plan has to pay for the medication 
assisted treatment (G2067) provided on December 5, 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 procedure code 99308 provided on November 9, 2022. 
 
You asked the Plan to pay for procedure code 99308. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from 
November 7, 2022, to November 29, 2022. The Plan says, per Medicare guidelines, the provider must bill 
Original Medicare for the services provided on November 9, 2022. 
 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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for procedure code 99308 provided on November 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the ambulance services provided on 
November 24, 2022. 
 
You asked the Plan to waive the cost share for the ambulance services. You say that the ambulance took too 
long to arrive to the hospital due to taking the wrong roads. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to ambulance services. The Plan 
contract also says that enrollees must pay a $100 copayment after meeting the deductible for each one-way 
ambulance service. 
 You have been asked to pay $524.88 towards your deductible. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to ambulance services. This cost sharing 
is a contractual obligation that had not been met at the time the ambulance services was received on November 
24, 2022. 
 
You have also been asked to pay $8.34, which is less than the standard $100 copayment for the ambulance 
service. This item/service falls within the ambulance services benefit category. You have been asked to pay a 
total of $533.22 ($524.88 deductible + $8.34 copayment = $533.22). 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 
cost share for the ambulance services provided on November 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0301). 
 
You asked the Plan to pre-approve the heavy duty extra wide hospital bed. You say that this bed is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty hospital bed is covered when the 
beneficiary's weight is more than 350 pounds but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The records show the beneficiary weighs 250 to 300 pounds. Based 
on this information, we decided that Medicare rules for coverage of the heavy duty extra wide hospital bed 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide 
hospital bed (E0301).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network physical therapy services. 
 
You asked the Plan to pre-approve out-of-network physical therapy services. You say that the enrollee would 
like to receive physical therapy treatment with this out-of-network provider and that the enrollee will not go 
back to the previous physical therapy office. The Plan denied your request. The Plan says the enrollee must 
receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
out-of-network physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 17, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
November 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the nasal endoscopy provided on February 
2, 2023. 
 
You asked the Plan to waive the deductible for the nasal endoscopy. You say that you are being over charged. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
the nasal endoscopy was received on February 2, 2023. Therefore, we decided that the Plan does not have to 
waive the deductible for the nasal endoscopy provided on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit provided on November 07, 2022. 
 
You asked the Plan to pay for an outpatient clinic visit. You say that this service is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient clinic visit 
provided on November 07, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the medication assisted treatment (G2067) provided on November 28, 
2022. 
 
You asked the Plan to pay for the medication assisted treatment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The facility where the provider rendered the services is enrolled with Medicare 
as an OTP. The OTP is the billing provider and is Substance Abuse and Mental Health Services Administration 
(SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the 
OTP meets the Medicare coverage criteria. Therefore, we decided that the Plan has to pay for the medication 
assisted treatment (G2067) provided on November 28, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 21, 2022.
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee is a 65-year-old male with tonsillar cancer status post radiation and 
dysphagia on feeding tube who presented to the emergency department with gastrostomy tube dislodgement. 
His vitals were stable. Examination revealed tenderness of abdomen, but no drainage. Labs were unremarkable. 
Surgery was consulted to place Foley catheter in gastrostomy. He was admitted for G-tube replacement. Due to 
the stability of the enrollee and expectation for a short uncomplicated procedure, it was not expected that the 
enrollee would require hospital services that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on May 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the drug administration and hospital 
observation services provided from September 28, 2022, to September 29, 2022. 
 
You asked the Plan to reduce the cost share for the drug administration and observation services. You say that 
you were admitted from your doctor's office and have only paid $90 in the past. 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 drugs. Your contract with the Plan also clearly says that you must pay a $250 copayment for hospital observation services. 
 
You have been asked to pay 20% coinsurance for the drug administration services. These items/services fall 
within the Medicare Part B drugs benefit category. You have also been asked to pay a $250 copayment for the 
hospital observation services. 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 reduce the cost share for the drug administration and hospital observation services provided 
from September 28, 2022, to September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the psychiatric services provided on 
November 22, 2022. 
 
You asked the Plan to waive the copayment for the psychiatric services. You say that in the past you always 
had a $0 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 $10 
copayment for outpatient psychiatric mental health care. 
 
You have been asked to pay a $10 copayment for the psychiatric services. This item/service falls within the 
outpatient psychiatric mental health 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 the psychiatric services provided on November 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from an 
LTACH admission to regain a maximum/prior level of functioning and continue a multidisciplinary approach 
to care. The Plan denied your request. The Plan says the requested LTACH admission 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 all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy, for treatment of incompetent extremity 
truncal veins and other incompetent extremity veins (code 36471). 
 
You asked the Plan to pre-approve sclerotherapy, for treatment of incompetent extremity truncal veins and 
other incompetent extremity veins. You say that sclerotherapy, for treatment of incompetent extremity truncal 
veins and other incompetent extremity veins is medically necessary. The Plan denied your request. The Plan 
says the requested sclerotherapy, for treatment of incompetent extremity truncal veins and other incompetent 
extremity veins is not medically necessary. 
 
The Plan follows Medicare rules.  
 
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 sclerotherapy, for treatment of 
incompetent extremity truncal veins and other incompetent extremity veins. Our reviewer says that the 
requested sclerotherapy, for treatment of incompetent extremity truncal veins and other incompetent extremity 
vein is not considered medically necessary in this case. Our physician reviewer found that the documentation 
does not meet coverage criteria and does not support the medical necessity of the procedures in question. As there is no evidence of varicose bleeding from the spider veins in question, the coverage criteria are not met.  
Additionally, there is nothing unique about this enrollees condition documented that would necessitate an 
overturn of this policy on the basis of medical necessity. The documentation is more supportive that the 
procedure is correctly being classified as cosmetic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy, for treatment of incompetent extremity truncal veins and other 
incompetent extremity veins have not been met. Therefore, we decided that the Plan does not have to pre-
approve sclerotherapy, for treatment of incompetent extremity truncal veins and other incompetent extremity 
veins (code 36471).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a unilateral x-ray of hip with pelvis, 2-3 views provided on 
October 06, 2022, billed with procedure code 73502.   
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the laterality of the diagnosis codes is mismatched. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral.  
 
We looked at the file and Medicare rules. Specifically, CPT code 73502 was billed with the LT modifier and a 
diagnosis code to indicate the left side. This claim was also billed with diagnosis code S79.919A, representing 
an unspecified side. This diagnosis lacks the anatomical site and specificity as required by Medicare coding 
guidelines. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a unilateral x-ray of hip with pelvis, 2-3 
views provided on October 06, 2022, billed with procedure code 73502.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 16, 2022, to December 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you had previously 
been in the hospital, and this should be considered a continuation of that stay. The Plan denied your request. 
The Plan says the cost sharing will be applied according to the Plan contract. 
 
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 $350 
copayment for each inpatient hospital admission.  
 
You have been asked to pay $350 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital 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 the inpatient 
hospital stay provided from December 16, 2022, to December 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccination provided on November 10, 2022. 
 
You asked the Plan to pay for the shingles vaccination. You say that you were told this vaccination was free of 
charge. The Plan denied your request. The Plan says that the shingles vaccination is not covered under your 
Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles 
vaccination. The Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccination. Therefore, we decided that the Plan does not have to pay for the shingles vaccination provided on 
November 10, 2022.