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

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on October 18, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 We asked our coder 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 service. Our reviewer found CPT code 99223 (1 unit) 
was not supported. This initial hospital care evaluation and management code requires a comprehensive 
history, a comprehensive examination and medical decision making of high complexity. However, the medical 
records submitted do not support a comprehensive history. The review has determined that the use of code 
99223 was not supported by the records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (99223) provided on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home BiPAP device would be sufficient. 
The enrollee has an extensive respiratory history for her COPD. Her PFT values have shown that her COPD is 
progressing to a more severe state which is also causing her to have a more frequent COPD exacerbation. The 
enrollee has been on various nebulized and inhaler medications to hopefully give some relief for her COPD, 
but treatment has not been effective. She will need a home noninvasive volume ventilation opposed to BiPAP-
AVAPS due to NIVV with AVAPS-AE has dual mode setting when she is in need of daytime rescue breathing. 
The Plan denied your request. The Plan says records do not show that the enrollee has failed treatment with 
CPAP or BIPAP or that the requested NIV will not be used exclusively in CPAP or bi-level PAP mode. The 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has diagnoses of COPD 
and Chronic respiratory failure with hypercapnia. The enrollee has chronic respiratory failure consequent to 
COPD. It is not documented that BiPAP with a back-up rate or volume-assured pressure support have been 
utilized and failed. Products classified as E0466 when used to provide CPAP or bi-level PAP shall not be paid 
in the FSS payment category, regardless of the underlying medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided on December 13, 2022. 
 
You asked the Plan to pay for initial hospital care.. You say that the enrollee was not enrolled in hospice at the 
time of service. 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 December 8, 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 initial hospital care 
provided on December 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from November 14, 2022, 
through November 15, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you do not agree with the denial and would 
like the claim 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 
from November 14, 2022, through November 15, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the mental health services provided by an 
out-of-network provider on September 28, 2022. 
 
You asked the Plan to waive the cost sharing for the mental health services. You say that you thought that this 
provider was in-network. 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 50% 
coinsurance for each out-of-network outpatient mental health service provided by a psychiatrist (individual or 
group sessions). 
 
 
 
 
 You have been asked to pay a $86.68 coinsurance for the mental health services ($173.37 allowed amount x .50 
= $86.68 rounded down). These items/services fall within the outpatient 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 cost sharing for the mental health services provided by an out-of-network 
provider on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI) 
services. 
 
You asked the Plan to pre-approve the SSBCI services. You say that you are appealing the denied services. The 
Plan denied your request. The Plan says that there was no documentation provided to show that the enrollee 
meets the criteria. 
 
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 did not provide us with medical records from their 
participating provider. Contracted providers are considered agents of the Plan. The Plan has not provided us 
with the information needed to make a determination regarding their denial and whether the criteria for SSBCI 
coverage have been met. Therefore, we decided that the Plan has to pre-approve special supplemental benefits 
for the chronically ill (SSBCI) services.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a biopsy provided on August 26, 2022. 
 
You asked the Plan to pay for a biopsy. You say that this should be covered. The Plan denied your request. The 
Plan says the 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 a biopsy provided on August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is doing remarkably well, consistent with their prior high functioning 
status. The enrollee is functioning at a home care level and does not require intensive rehabilitation services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical procedure provided on April 13, 2022. 
 
You asked the Plan to pay for a surgical procedure. You say that the claim needs to be reprocessed as the 
enrollee was not in hospice at the time of service. 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 April 12, 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 a surgical procedure 
provided on April 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for SNF services provided from September 1, 
2022, to September 16, 2022. 
 
You asked the Plan to reduce the copayment for SNF services. You say that you contracted Covid-19 during 
the SNF stay and was isolated for 10 days which prolonged your stay. 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 $0 
copayment for days 1 to 20 and a $178 copayment per day for days 21 to 100 for SNF services.  
 
You have been asked to pay a total copayment of $2,848 for SNF services ($178 per day x 16 days = $2,848). 
This item/service falls within the SNF 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 reduce the 
copayment for SNF services provided from September 1, 2022, to September 16, 2022.  Your complaint about having the SNF stay be prolonged due to contracting Covid-19 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alcohol swabs / skin barrier wipes. 
 
You asked the Plan to pre-approve alcohol swabs / skin barrier wipes. You say that you would like 
reconsideration because the requested alcohol swabs / skin barrier wipes are medically necessary. The Plan 
denied your request. The Plan says the requested alcohol swabs / skin barrier wipes are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve alcohol swabs / skin barrier wipes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says SSBCI is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition. Special supplemental benefits for the chronically ill (SSBCI) is not 
covered under the Plans benefits. 
 
We looked at the file and Medicare rules. Based on this information, SSBCI benefits are no listed in the 
Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve SSBCI benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110). 
 
You asked the Plan to pre-approve dental services. You say that you would like the request for dentures to be 
approved. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Complete upper denture 
(D5110) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5110 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve complete 
upper denture (D5110).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 10, 2022. 
 
You asked the Plan to pay for medical services. You say that this should be covered. The Plan denied your 
request. The Plan says the 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 medical services provided on June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the specialist visit, and the shoulder x-ray 
provided by an out-of-network provider on November 22, 2022. 
 
You asked the Plan to waive the cost sharing for the specialist visit and the x-ray. You say that you were told 
that this provider was in-network. 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 45% 
coinsurance of the total allowed amount, per provider per day, for each Medicare-covered out-of-network 
specialist office visit, and a 45% coinsurance of the total allowed amount for out-of-network Medicare-covered 
outpatient x-ray services. You have been asked to pay a $47.70 coinsurance for the specialist visit because the Plan is only holding you 
responsible for this amount, which is less than the 45% coinsurance. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay a $12.93 coinsurance for the x-ray because the Plan is only holding you responsible for this amount, which 
is less than the 45% coinsurance. 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 waive the cost sharing for the 
specialist visit, and the shoulder x-ray provided by an out-of-network provider on November 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on October 7, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that you did not know the physical therapy 
services were being provided by a chiropractor. The Plan denied your request. The Plan says that physical 
therapy services provided by a chiropractor are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for physical therapy services provided on October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric wheelchair. 
 
You asked the Plan to pre-approve the electric wheelchair. You say that you are in a lot of pain and need the 
wheelchair to get around. The Plan denied your request. The Plan says that there is no written order or in-home 
assessment for the requested wheelchair. 
 
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 written physician order or in-home assessment which support medical necessity 
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 pre-approve an 
electric wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on November 15, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that this should be covered you cannot afford 
the charge. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit. 
 
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 November 15, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the specialist office visits provided on 
November 22, 2022, and December 13, 2022. 
 
You asked the Plan to reduce the copayments for the specialist office visits. You say that the cost is 
unreasonable for the care you received. 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 $45 
copayment for each in-network Medicare-covered visit with a specialist. 
 
You have been asked to pay a $45 copayment for each specialist office visit. You have been asked to pay a 
total of a $90 copayment ($45 copayment x 2 visits = $90). These items/services fall 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 reduce the copayments for the specialist office visits 
provided on November 22, 2022, and December 13, 2022.