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

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on October 18, 
2021. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you were told there was no 
copayment for COVID procedures. The Plan denied your request. The Plan says the proper copayment was 
applied for the claim that was billed and there are no COVID codes that was billed on the claim. 
 
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 In-Network Specialist Virtual Telehealth Services.  
 
  You have been asked to pay a $45 copayment for the telehealth visit. The telehealth visit falls within the 
Physician/Practitioner services, including doctor's 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 a telehealth visit provided on October 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
March 8, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived because of the service you received. The Plan denied your request. The Plan says the proper 
copayment was applied for the service that was rendered 
 
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 $75 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $75 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency 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 an 
emergency room visit provided on March 8, 2022.  
 Your complaint about your experience with this 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chemotherapy administration services 
provided from January 11, 2022, to February 11, 2022. 
 
You asked the Plan to waive the copayments for the chemotherapy administration. You say that you were not 
aware of any cost changes for the service. 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 $30 
copayment for the administration of chemotherapy drugs.  
 
The file shows you had a total of 10 visits for chemotherapy administration from January 11, 2022, to February 
11, 2022. Therefore, you have been asked to pay a $30 copayment for each chemotherapy administration, for a 
total of $300 ($30 copayment x 10 visits = $300). The chemotherapy administration falls 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 waive the copayments for 
chemotherapy administration services provided from January 11, 2022, to February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two pairs of eyeglasses purchased from an online retailer on 
March 17, 2022. 
 You asked the Plan to pay for eyeglasses. You say that you were not told you had to use a contracted provider 
for eyewear. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's 
specified vision vendor network. Eyewear is only covered when purchased through this network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses up to $150 per year when they are received from an in-
network provider. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified vision 
network. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been 
met. Therefore, we decided that the Plan does not have to pay for two pairs of eyeglasses purchased from an 
online retailer on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on April 5, 2022, by an out-of-
network (OON) podiatrist. 
 
You asked the Plan to pay for the outpatient visit. You say that you have tried to find an in-network podiatrist 
to no avail. The Plan denied your request. The Plan says the services have been provided out-of-network and 
were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient visit provided on April 5, 2022, by 
an out-of-network (OON) podiatrist.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from May 19, 2021, to May 28, 2021. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) score. 
 
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 Section I, dated May 26, 2021, 
lists "OTH DISRD INVOLVING THE IMMUNE MECHANISM, NEC" under the heading additional active 
diagnoses. However, the case file does not contain clinical documentation supporting an active diagnosis of 
"other disorder involving the immune mechanism." 
 
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 skilled nursing facility (SNF) services provided to the enrollee from May 19, 2021, to May 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for open procedures involving hip joint (01215) 
provided on February 28, 2021. 
 
You asked the Plan to pay for the anesthesia (01215). You say that the enrollee had two surgeries in the same 
day at different operative times and the second case did not process correctly. You say that the claim should be 
reprocessed and payment of $199.11 issued. The Plan denied your request. The Plan says a modifier is not 
allowed to bypass the code pair edit.  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 01215 
is a column II code to column I code 01214 with a modifier indicator of 0. The column II code is therefore not 
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 anesthesia for open procedures involving hip joint (01215) provided on 
February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wellness exam (G0402) provided January 17, 2022. 
 
You asked the Plan to pay for the wellness exam. You say that this service was medically necessary. The Plan 
denied your request. The Plan says a wellness exam was already covered in the previous 12 months, another 
exam is not eligible for coverage. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for a wellness exam (G0402) provided January 17, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (durvalumab) injections. 
 
You asked the Plan to pre-approve the durvalumab treatments. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the enrollee's cancer was resected and the guidance 
specifically states that this does not support the use of durvalumab. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 durvalumab treatments. Our 
reviewer says that the requested treatment is not considered medicaally reasonable and necessary. Our 
physician reviewer found the enrollee is a 71-year-old man with a diagnosis of stage IIIA adenocarcinoma of 
the left lung. The enrollee has undergone lower lobectomy. Chemotherapy was initiated with carboplatin and 
pemetrexed which resulted in significant issues with mucositis. The enrollees regimen was then changed to 
carboplatin and paclitaxel, which resulted in neuropathic changes in his lower extremities. The enrollee 
declined radiation therapy. The enrollee was found to be strongly positive for PDL1, and adjuvant Durvalumab has been requested.  
 
Durvalumab is recommended for Non-small cell lung cancer, Unresectable Stage III, without progression 
following concurrent platinum-based chemotherapy and radiation therapy. The documentation does not support 
that the enrollee has received concurrent platinum-based chemotherapy and radiation therapy. 
 
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 durvalumab treatments have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Imfinzi (durvalumab) injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound treatment from December 10, 
2021, to March 2, 2022. 
 
You asked the Plan to waive the copayments for wound treatment. You say that this was an ulcer debridement, 
which it is not a surgery, and that you do not agree with $225 copayment for each visit. The Plan denied your 
request. The Plan says there is a $225 copayment for each Medicare-covered Outpatient Hospital Facility visit. 
It states in the Evidence of Coverage (EOC) that "wound debridement" is considered an In-Network, Outpatient 
Surgery.  
 
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 $225 for 
In-network, Outpatient Surgery. There were 13 covered visits, each with a copayment of $225, equaling a total 
copayment amount of $2,925. 
 
You have been asked to pay $225 for wound treatment. Wound treatment falls within the In-network, 
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 waive the copayments for wound treatment from December 10, 2021, to 
March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenesis stimulator, electrical, non-invasive, other 
than spinal applications (E0747). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that the ordering physician has asked 
you to appeal this determination based on the additional medical record as well as the published medical 
studies addressing the efficacy of your device. The Plan denied your request. The Plan says the enrollee has a 
navicular fracture and not a long bone fracture and does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve osteogenesis stimulator, electrical, non-invasive, other than spinal applications (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 30, 2021. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 9, 2021. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L2820, L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you do not need a covered brace or shoes. You 
have orthotics prescribed for severe foot pain and overpronation. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L2820, L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 4, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has a history of chronic 
low back pain and has failed non-operative treatment. You say that this procedure is the only solution and 
should be approved. The Plan denied your request. The Plan says experimental and investigational services are 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental, and more research is needed. 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and this 
claim should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
device (K0554) and related supplies (K0553) 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and related supplies. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
for CGMs and related supplies have not been met. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre CGM and related supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) device (K0554) and related supplies 
(K0553)