Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to reimburse you for repair or nonroutine service for durable medical equipment 
other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes (K0739) and 
sales tax (S9999) provided January 26, 2022. 
 
You asked the Plan to reimburse you for the DME repair services. You say that you were told multiple times 
that the DME would be reimbursed at 80% of the amount you paid. The Plan denied your request. The Plan 
says that the claim was processed correctly per the Evidence of Coverage. 
 
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 enrollees must pay $30% coinsurance for out of network Durable medical 
equipment (DME).  
 
You received reimbursement of $11.84 for the DME repair services. Based on the Plan contract, however, you 
cannot be asked to pay more than $30% coinsurance for the DME repair services. The records show that you 
paid the total amount of $407.34. Since the total amount was paid, the Plan should have issued total 
reimbursement minus the 30% coinsurance amount of $5.08. The correct reimbursement should have been for 
$390.42. Since you received a reimbursement of $11.84, you are still owed reimbursement of $378.58. 
Therefore, we decided that the Plan has to reimburse you for repair or nonroutine service for durable medical 
equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes 
(K0739) and sales tax (S9999) provided January 26, 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 optometry services provided on March 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for optometry services. You say that you were out of town when your glasses broke. 
You say you cannot drive without your glasses. The Plan denied your request. The Plan says you received 
services from an out-of-network provider, and the services are 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 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. The services you received are not considered an emergency or urgently needed care. 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 optometry services provided on March 3, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on January 24, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was already processed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation includes Provider remittance advice for reimbursement of CPT 20610 (1 unit) with check date 3/3/22. The procedure 
report documents, "After sterile prep of the skin with alcohol, the knee was injected with Gelsyn." In this case 
additional units of CPT 20610 is not supported.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies received from January 17, 2022, to 
March 15, 2022. 
 
You asked the Plan to pay for incontinence supplies. You say that this have really helped. The Plan denied your 
request. The Plan says the Pure Wick external catheters have stopped being supported by Medicare as of July 
2021 due to a lack of clinical studies establishing medical necessity for coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies received from 
January 17, 2022, to March 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you have gotten progressively weak due to COVID-
19 and are unable to stand without assistance. You say that you feel you are at risk for falls at home. The Plan 
denied your request. The Plan says you do not meet the criteria for coverage of an admission to an SNF. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have stabilized medically and are ready for discharge from the hospital. You do 
not require skilled nursing and/or skilled therapy services on a daily basis. Although further rehab services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing facility. You are medically stable without any acute 
exacerbations of chronic medical conditions and do not have any parental medication; complex wound care or 
nutrition given via a feeding tube. Your physical function is at or near your baseline and you can receive 
services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not 
medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting you had on March 8, 2022. 
 
You asked the Plan to pay for the contact lens fitting. You say that due to your eye conditions, you require 
specialty contact lenses.  This should be approved because this service was medically necessary. The Plan 
denied your request. The Plan says contact lens fitting is not a covered benefit. 
 Medicare generally does not cover routine vision and eye wear services. However, the Plan offers a routine 
vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The only additional vision items/service that the Plan covers are prescription eyewear and routine eye 
exams.  There is no coverage listed in your contract for contact lens fittings. 
 
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 contact lens fitting have not been met. Therefore, we decided that the Plan does not have to pay 
for the contact lens fitting you had on March 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be transferred to an IRF to 
continue her care post-discharge. The Plan denied your request. The Plan says the criteria for admission to an 
IRF are not met in this case; the enrollee can safely be treated in a lower level of care. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee does continue to need skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation does not 
support that the criteria for admission to an acute inpatient rehabilitation facility are met. There is no indication 
that the enrollee would require a minimum of 15 hours per week of skilled rehabilitation services in an IRF 
under the supervision of a physician with at least three physician visits weekly to regain or maintain functional 
status. The enrollee can receive further services at a lower level of care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 11, 2021, billed with 
codes 81206, 81235, 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says correct coding requires that when a panel code is ordered, it should be billed, rather 
than the individual gene codes. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 11, 2021, billed with codes 81206, 81235, 81321.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99152 billed for date of service March 25, 2022. 
 
You asked the Plan to pay for code 99152. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99152 is not supported in the medical record. Codes 92958-LD, 
92978-26-LD have been overturned and the claim sent back for reprocessing. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 
5 years or older. 
 
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 code 99152. Our reviewer says that code 99152 is not 
supported in the medical record. Our reviewer found the medical record does not include documentation to 
support a independent trained observer, other than the physician performing the primary service was present to 
assist in monitoring of the patient's level of consciousness and physiological status per CPT code 
description. Therefore this procedure cannot be verified. as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99152 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99152 billed for date of service March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the cost for the CGM sensors provided on December 29, 2021, and 
January 31, 2022. 
 
You asked the Plan to waive the cost for the CGM sensors. You say that you canceled this when your doctor 
took you off and you do not hold responsibility for this bill. The Plan denied your request. The Plan says that 
the cost share applied 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 does not say in clear and accurate terms 
when you would be expected to pay $0 for diabetic services and supplies or pay based on the durable medical 
equipment benefit.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% 
coinsurance for CGM sensors. The Plan contract does not clearly say when you would be expected to pay $0 
for diabetic services and supplies or pay based on the durable medical equipment benefit. This means that the 
Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the 
Plan has to waive the cost for the CGM sensors provided on December 29, 2021, and January 31, 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 waive the copayment for the nasal endoscopy provided on October 
15, 2021. 
 
You asked the Plan to waive the copayment for the nasal endoscopy. You say that you had a doctor office visit, 
not a hospital visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 surgery provided at an outpatient hospital.  
 
The record shows you received services at an outpatient hospital clinic. The record also shows the nasal 
endoscopy is considered a surgical service. You have been asked to pay a $200 copayment for the nasal 
endoscopy. The nasal endoscopy falls within the Outpatient Surgery and Other Medical Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 nasal endoscopy provided on October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs care at an IRF. The Plan denied 
your request. The Plan says the criteria for coverage of an IRF admission are not met in this case. The services 
the enrollee needs can safely be provided in an alternate setting. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee does continue to need skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation does not 
support that the criteria for admission to an acute inpatient rehabilitation facility are met. There is no indication 
that the enrollee would require a minimum of 15 hours per week of skilled rehabilitation services in an IRF 
under the supervision of a physician with at least three physician visits weekly to regain or maintain functional 
status. The enrollee can receive further services at a lower level of care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for hematology services provided on March 25, 2022. 
 
You asked the Plan to hold you harmless for the hematology services. You say that you had met your out-of-
pocket maximum for the year prior to these services. The Plan denied your request. The Plan says that the 
provider left the group and cannot be paid.  The provider is a non-pay provider now and the Plan has not 
received additional information from them. 
 
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, in the file it submitted to us, the Plan included a letter from them 
that explicitly said that as of February 11, 2022, you had met your out-of-pocket maximum and would not have 
to pay cost sharing for the rest of the year.  Further, the Plan has failed to provide any explanation as to why 
you are getting charged for these hematology services beyond the fact that this provider is listed in their system 
as a 'non-pay' provider.  The case file that the Plan sent us shows that the provider you saw is a contract 
provider with the Plan.  If there is an issue regarding this provider's payment status with the Plan, that is an 
issue between the Plan and the provider.  You should not be held responsible for billing issues between the 
Plan and their own contract provider.  The Plan has failed to provide any evidence showing that you have no 
obligation to pay the balance on the claim for this service. The burden is on the Plan to show why its denial or 
non-payment of services was appropriate.  The Plan has failed to provide any such documentation supporting 
this argument in the case file it submitted to us. Therefore, we decided that the Plan has to hold you harmless 
for hematology services provided on March 25, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for Renflexis injections provided on April 12, 
2022, and May 24, 2022. 
 
You asked the Plan to reduce the coinsurance for the injections. You say that the amount you owe has almost 
doubled this year. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a total of $1,026.40 for the injections.  
 
Date of Service Allowed Amount 20% Coinsurance 
April 12, 2022 $2,382.71 $476.54 
 $305.48 $61.10 
May 24, 2022 $2,321.61 $464.32  $122.19 $24.44 
Totals $5,131.99 $1,026.40 
 
 
The injections fall within the Medicare Part B Prescription Drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the coinsurance for Renflexis injections provided on April 12, 2022, and May 24, 2022.  
 
Your complaint about how much the cost has increased 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.