Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 10, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the claim needs to be reprocessed. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 subsequent nursing facility care provided on October 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing test and the specialist visit 
provided by an in-network provider on August 29, 2022. 
 
You asked the Plan to waive the copayment for the hearing test and the specialist visit. You say that you do not 
think you should be responsible for the copayment for these services. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for in-network Medicare-covered hearing services, and a $30 copayment for each in-network 
Medicare-covered specialist visit. 
 
You have been asked to pay a $20 copayment for the hearing test because the Plan is only holding you 
responsible for this amount, which is less than the $30 copayment. This item/service falls within the hearing 
services benefit category. You have also been asked to pay a $30 copayment for the specialist visit. 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 copayment for the hearing test and the specialist visit provided by an in-
network provider on August 29, 2022.  
 
Your complaint about your dissatisfaction with the provider is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 18, 2022. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
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 services provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on October 3, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on October 3, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on June 
09, 2022, through June 12, 2022. 
  
You asked the Plan to pay for the SNF services.. You say that the enrollee was not enrolled in Hospice until 
after the date of service and would like the claim to be resubmitted and paid accordingly. The Plan denied your 
request. The Plan says services should be billed under Original Medicare. 
 
 
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 June 10, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility 
(SNF) services provided on June 09, 2022, through June 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the spinal canal. 
 
You asked the Plan to pre-approve an MRI of the spinal canal. You say that you have constant back pain that 
was being treated with prescription medication but are no longer able to take. The Plan denied your request. 
The Plan says the MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the spinal canal. Our 
reviewer says that an MRI is not medically reasonable or necessary. Our physician reviewer found during the 
most recent encounter, no neurological exam was done, and no red flags were noted. A six-week trial of 
physical therapy is recommended before moving forward with an MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the spinal canal have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the spinal canal.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 5, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
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 services provided on December 5, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99283 and 99053 billed for date of service 
November 22, 2022. 
 
You asked the Plan to pay for procedure codes 99283 and 99053. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 99283 is 
bundled into payment for code 99284. Additionally, procedure code 99053 is considered bundled and not 
separately payable. 
 
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 99283 
is a column II code to column I code 99284. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, we find that procedure code 99053 has a status indicator of B on the Physician 
Fee Schedule. This means that procedure code 99053 is not separately payable. 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 codes 99283 and 99053 billed for date of service November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Kit Sensor. 
 
You asked the Plan to pre-approve the Freestyle Kit Sensor. You say that you need this to measure your blood 
sugar often during the day, both low and high. You also say that you have lost weight and it is all over the 
place. The Plan denied your request. The Plan says that you do not have additional supplemental benefit for 
continuous glucose monitor beyond what is covered by Medicare. 
 
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 Plan has not provided us with any medical records or evidence 
of having made reasonable attempts to obtain the medical records. Without this necessary information we are 
unable to make a determination regarding the medical necessity of the Freestyle Kit Sensor. The Plan has not 
substantiated their denial reason. Therefore, we decided that the Plan has to pre-approve a Freestyle Kit Sensor.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for open treatment of femoral shaft fracture provided on 
September 3, 2022. 
 
You asked the Plan to pay for open treatment of femoral shaft fracture. You say that the provider was 
underpaid for the surgery and are not subjected to contracted fees. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment.  
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 open treatment of femoral shaft fracture provided on 
September 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that the enrollee needs this. The Plan denied your request. 
The Plan says the requested CGM is not medically necessary. 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and injection services provided on October 4, 
2022. 
 You asked the Plan to pay for office visit and injection services. You say that the claim should be reprocessed 
for payment. The Plan denied your request. The Plan says services should be billed under Original Medicare. 
 
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 October 3, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit and 
injection services provided on October 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 14, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 14, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the denosumab injection and the drug 
administration provided by an in-network provider on December 30, 2022. 
 
You asked the Plan to reduce the cost sharing for the injection and the administration. You say that you would 
like the cost sharing to be lower. 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 in-network Medicare Part B covered drugs provided at all locations of service, and a $40 
copayment for in-network diagnostic procedures and tests provided at an outpatient hospital. 
 
You have been asked to pay a $278.22 coinsurance for the injection ($1391.12 allowed amount x .20 = 
$278.22). This item/service falls within the Medicare Part B prescription drugs benefit category. You have also 
been asked to pay a $40 copayment for the administration. This item/service 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 reduce the 
cost sharing for the denosumab injection and the drug administration provided by an in-network provider on 
December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the TBS test provided on December 15, 
2022. 
 
You asked the Plan to waive the copayment for the TBS test. You say that this should have been included with 
the no cost share bone mass measurement. 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 states that other cost share 
amounts can apply during a bone mass measurement. Your contract with the Plan also clearly says that you 
must pay a $45 copayment for each specialist office visit.  
 
You have been asked to pay $39.76, which is less than the standard $45 copayment for the TBS test. This 
item/service falls within the physician/practitioner services 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 trabecular bone score (TBS) test provided on December 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on December 25, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that the claim needs to be reprocessed. The 
Plan denied your request. The Plan says self-administered drugs do not fall under Part B coverage. 
   
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on December 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care provided on November 4, 2022. 
 You asked the Plan to pay for critical care. You say that the claim needs to be reprocessed. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
   
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 November 3, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for critical care provided 
on November 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammography provided on August 4, 2022. 
 
You asked the Plan to pay for the screening mammography. You say that the screening mammography was 
medically necessary. The Plan denied your request. The Plan says the benefit level has been reached for the 
year. 
 
The Plan contract covers one screening mammogram every 12 months for women age 40 and older. 
 
We looked at the file and the Plans rules. The file shows that you received coverage a screening mammogram 
on July 29, 2022. Therefore, we decided that the Plan does not have to pay for a screening mammography 
provided on August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for IRF services provided from September 6, 
2022, to September 10, 2022. 
 
You asked the Plan to waive the copayment for IRF services. You say that the member was not notified of the 
copayment and should not be held responsible to pay it. 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 $335 copayment for each day for days 1 to 6 and $0 copayment for additional days for each 
Medicare-covered inpatient hospital care.  
 The enrollee has been asked to pay a $1,340 copayment for IRF services ($355 per day x 4 days = $1,340). 
This item/service falls within the inpatient hospital 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 IRF services provided from September 6, 2022, to September 10, 2022.  
 
Your complaint about not being notified of the copayment is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on September 30, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services received on 
September 30, 2022. 
 You asked the Plan to pay for the SNF services.. You say that the decision be reversed, and the claim 
resubmitted for payment. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services received on 
September 30, 2022.