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

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) 
device provided from September 22, 2021, to October 22, 2021. 
 
You asked the Plan to waive the coinsurance for the AED device. You say that you had no idea the equipment 
rental would cost over $1,600. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 durable medical equipment (DME), including AED devices. Item Allowed Amount 20% Coinsurance 
AED  September 22, 2021 $2,704.94 $540.99 
AED  October 22, 2021 $2,704.94 $540.99 
Total:  $1,081.98 
 
You have been asked to pay $1,081.98, which is 20% of the allowed amount for the AED device. The AED 
device falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for an automatic external defibrillator (AED) device provided from 
September 22, 2021, to October 22, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Vitamin D testing (code 82306) billed for date of service June 24, 
2021. 
 
You asked the Plan to pay for code 82306. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that lab services ordered for screening purposes are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Vitamin D testing billed with code 82306 is 
coverable when billed with diagnosis code E55.9 (Vitamin D Deficiency, unspecified), as this is a code that 
supports medical necessity for procedure code 82306. The claim in this case was billed with diagnosis code 
E55.9.  There is no evidence that this testing was ordered for screening purposes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 82306 have been met. Therefore, we decided that the Plan has to pay for Vitamin D testing 
(code 82306) billed for date of service June 24, 2021.  
 
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 pre-approve the MAZE procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this procedure is helpful. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's atrial fibrillation is described as being of longstanding and with very enlarged 
atrium. As such, the the enrollee would not be considered a suitable candidate for MAZE procedure according 
to current guidelines. Echocardiography shows a patent foramen ovale (PFO), which could be surgically closed 
at time of valve replacement if felt to be clinically indicated, rather than carrying out separate percutaneous 
closure. In summary, MAZE procedure and percutaneous PFO closure would not be considered medically 
appropriate and necessary in this enrollee's clinical management. 
 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MAZE procedure for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided July 
19, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that this appeal should be granted because the 
services provided were medically necessary. The Plan denied your request. The Plan says the services are not 
supported without required documentation. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services 
(90832) provided July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 the laboratory services rendered on January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee is 
scheduled for removal of a lap band placed for weight loss. The record does not state that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights nor does the record support the 
need for such a stay. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not the standard of care for prostate cancer. 
 
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 therapy. Our reviewer says that the 
requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer 
found any potential benefit or detriment of proton therapy over standard intensity-modulated radiation therapy 
(IMRT) is an investigational question (being pursued in randomized studies- i.e. for intermediate to low risk 
prostate cancer. Other treatment approaches are also highly effective and well tolerated. Thus, whether proton 
therapy affords a benefit over other standard approaches for prostate cancer is an area of investigation and 
remains controversial. To date, there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than IMRT/ image-guided radiation therapy (IGRT). The generally accepted standard of care 
for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to 
patients.  
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the duration of conservative care is not clearly stated. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. 
 Our physician reviewer found the enrollee has not completed at least three (3) months of adequate conservative 
care including physical therapy and/or chiropractic manipulation. The duration of the conservative care is not 
clearly stated, and the reported conservative care of non- steroidal anti-inflammatory medication, independent 
exercise program, and activity modification/rest does not completely satisfy the guidelines. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing should be covered because it was 
medically necessary. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. The Plan says that you billed with a place of service of 11 (office), however, the records show 
that the specimen was obtained in a skilled nursing facility, which would be place of service 31.  
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.  
 
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 an office POS code. 
The records do not support that the sample was taken in an office setting. Therefore, we decided that the Plan 
does not have to pay for lab services provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunization administration provided on May 5, 2021. 
 
You asked the Plan to pay for the immunization administration. You say that you are not sure why this claim 
was denied. You say that this was a COVID-19 vaccine, and the claim should be reprocessed. The Plan denied 
your request. The Plan says the service remains denied. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare Advantage patients you vaccinated 
in 2021, submit COVID-19 vaccine administration claims to Original Medicare through your Medicare 
Administrative Contractor (MAC). Use your patients Medicare Beneficiary Identifiers (MBIs) to bill Original 
Medicare.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the immunization administration have not been met. Specifically, Original Medicare is responsible 
for payment. Therefore, we decided that the Plan does not have to pay for the immunization administration 
provided on May 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mvasi (Q5107). 
 
You asked the Plan to pre-approve Mvasi. You say that Mvasi is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
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 Mvasi. Our reviewer says that Mvasi is 
not medically necessary. Our physician reviewer found the record shows the enrollee has cervical cancer with 
prior progression on Avastin. Mvasi is not recommended given the prior progression. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mvasi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Mvasi (Q5107).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bronchoscopy, rigid or flexible, including fluoroscopic 
guidance, when performed (31622) provided on April 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a bronchoscopy, rigid or flexible, including fluoroscopic guidance, when 
performed. You say that you are appealing with supporting records. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan and the services were not referred by a network 
provider or rendered in an in-network facility. The Plan also says that they have 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 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 a bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed (31622) provided on April 13, 2021, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical records provided support the 
need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH 
care have not been met. The Plan says that the enrollee can safely receive the care needed in the current 
hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with a urinary tract infection 
(UTI), pneumonia, sepsis, acute respiratory failure, and seizures complicated by encephalopathy and acute 
kidney injury. The enrollee was treated with mechanical ventilation support, steroids, and IV antibiotics. A 
trach was placed. Recent notes describe the enrollee as now tolerating the trach collar but requires ongoing 
simple wound care and additional weaning.  The enrollee appears to be stable and improving and should only require short-term additional acute care 
services that can be safely completed at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. Transfer to an LTACH is not medically necessary 
as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment 
has completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an after cataract laser eye surgery 
performed on November 10, 2021. 
 
You asked the Plan to waive the copayment for the eye surgery. You say that you are on social security and 
cannot afford the charges. 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 $350 
copayment per day for outpatient procedures and services.  
 
You have been asked to pay $254.05, which is less than the $350 copayment for the eye surgery. The eye 
surgery falls within the Outpatient Surgery, Including 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 an after 
cataract laser eye surgery performed on November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share for the computed tomography, of the thorax, 
diagnostic; with contrast material (71260) and the low osmolar contrast material, 300-399 mg/ml iodine 
concentration, per ml (Q9967) provided on November 26, 2021. 
 
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
item/service provided. 
 
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 $175 
copayment for each in-network Medicare-covered diagnostic imaging service. Additionally, you pay a 20% 
coinsurance for each Medicare-covered Part B drug.   
You have been asked to pay $176.14 which includes a $175 copayment for the in-network Medicare-covered 
diagnostic imaging service and the Plans allowable amount of $5.71 x 20% coinsurance= $1.14 for the 
Medicare-covered Part B drug injection provided. 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 adjust the cost share for the 
computed tomography, of the thorax, diagnostic; with contrast material (71260) and the low osmolar contrast 
material, 300-399 mg/ml iodine concentration, per ml (Q9967) provided on November 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is not covered under the enrollee's medical 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 pre-approve Eliquis 5 mg tablet.  
 
Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.