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

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on January 18, 2022. 
 
You asked the Plan to pay for a nursing facility care visit. You say that the provider saw the enrollee in a 
hospital and should not be penalized for the failure of the hospital to obtain authorization. The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 
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 nursing facility care visit provided on January 
18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services and hospice/home health care 
services provided on January 21, 2022, to February 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services and hospice/home health care services. You say that you 
requested authorization, but the request came back stating that no authorization was needed for the billed 
services. The Plan denied your request. The Plan says services from non-participating providers are not covered 
under open access unless pre-authorized. 
 
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 skilled nursing services and hospice/home health 
care services provided on January 21, 2022, to February 19, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inpatient psychiatric services provided July 13, 
2022, forward. 
 
You asked the Plan to pre-approve the inpatient psychiatric services. You say that the inpatient psychiatric care 
is medically necessary. The Plan denied your request. The Plan says you have exhausted your 190-day lifetime 
limit for inpatient services in a psychiatric hospital. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment. The Plan contract says that there is a 190-day lifetime limit for inpatient 
services in a psychiatric hospital. 
 
We looked at the file and Medicare rules. In this case you have exhausted your 190-day lifetime limit for 
inpatient psychiatric services on July 12, 2022.  Therefore, we decided that the Plan does not have to pre-
approve the inpatient psychiatric services provided July 13, 2022, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgery services provided on December 
10, 2021. 
 
You asked the Plan to waive the copayment for the surgery services. You say that your copayment should be 
$275, not $325. The Plan denied your request. The Plan says the copayment was applied correctly. Please note, 
the $275 copayment specifies ambulatory surgical center and the $325 copayment is for outpatient hospital, so 
the place of service for the surgery determines the copayment in this instance.  
 
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 $325 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
  You have been asked to pay $325 for the surgery services. The surgery services fall 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 outpatient surgery services 
provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on December 13, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was provided to the enrollee 
out of medical necessity, and you would like the claim to be processed for payment. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 nursing facility care provided on December 13, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiology services provided on March 11, 
2022. 
 
You asked the Plan to waive the copayment for radiology services. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says you were 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 $300 
copayment for Medicare-covered diagnostic radiology services (not including x-rays).  
 
 
 
 
 
 You have been asked to pay a $300 copayment for radiology services. Radiology services fall 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 copayment for radiology services provided on March 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99306) provided on August 
19, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial nursing facility care (99306) provided on August 
19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hip replacement procedure performed 
from February 8, 2022, to February 9, 2022. 
 
You asked the Plan to waive the coinsurance for the hip replacement. You say that your two day stay should be 
billed as inpatient. 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 25% 
coinsurance for surgery provided at an outpatient hospital.  
 
You have been asked to pay $2,731.34, which is less than 25% of the allowed amount for the hip replacement 
($11,974.93 allowed amount x 25% coinsurance = $2,993.73).Tthe hip replacement 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 coinsurance for a hip replacement procedure performed from 
February 8, 2022, to February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you believe 
this service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the 
LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0667).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on April 30, 2021. 
 
You asked the Plan to pay for an x-ray. You say that you are appealing the denial for services rendered. The 
Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 an x-ray provided on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital hearing aids (V5261) and dispensing fee (V5160) 
provided from January 13, 2022, to March 2, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the digital hearing aids and dispensing fee. You say that you would like to be 
reimbursed $1,500. The Plan denied your request. The Plan says you used a non-participating provider to 
purchase the hearing aids and are not eligible for reimbursement. The Plan also says that you did not contact 
the Health Plan regarding the hearing aid benefit until after you purchased the hearing aids from the OON 
provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plan's hearing aid vendor.  
 
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 digital hearing aids and dispensing fee have not been met. Therefore, we decided that the Plan 
does not have to pay for the digital hearing aids (V5261) and dispensing fee (V5160) provided from January 
13, 2022, to March 2, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from June 10, 2021, to June 18, 2021. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that you feel the patient does meet inpatient 
criteria, and it was medically necessary for him to be admitted, monitored, and treated as an inpatient. The Plan 
denied your request. The Plan says that the documentation does not show the enrollee had trouble thinking 
clearly, a stroke or heart attack, a lot of fluid in their lungs, new seizures, severe damage to their kidneys, 
and/or serious problems in their eyes. The Plan also says that this might be an observation 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 pay for the inpatient hospital stay. Our reviewer says 
that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
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 inpatient hospital stay have been met. Therefore, we decided that the Plan 
has to pay for the inpatient stay provided from June 10, 2021, to June 18, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a skilled nursing facility (SNF) admission. You say that the enrollee is home 
alone and needs a mobility environment until he can be home by himself. The Plan denied your request. The 
Plan says based on Medicare guidelines and the information we have about the enrollee's condition they do not 
meet all the requirements. 
 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 a skilled nursing facility (SNF) 
admission. Our reviewer says that based on the medical records provided there is no documentation that the 
enrollee requires skilled nursing services. Our physician reviewer found the enrollee is walking household 
distances with supervision and no assistive device. The enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
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 skilled nursing facility (SNF) admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on December 10, 
2021. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that on the Plan's letter dated February 
7, 2022, the bottom paragraph says that purchases prior to February 15 will be reimbursed. The Plan denied 
your request. The Plan says this was not a covered benefit at the time you purchased the tests. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for over-the-counter (OTC) 
items and at-home COVID-19 test kits are an OTC item. However, the Plan offers a supplemental benefit for 
over-the-counter home COVID-19 tests purchased after February 1, 2022. These tests were purchased on 
December 10, 2021, which is before this benefit went into effect. Therefore, we decided that the Plan does not 
have to pay for the at-home COVID-19 test kits purchased on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on February 22, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that the providers rely on facility staff to 
verify eligibility and obtain authorization form the enrollee's Plan. The Plan denied your request. The Plan says 
the out-of-network services were not authorized. 
 
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 ophthalmological services provided on February 
22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) with 
contrast provided on September 17, 2021. 
 
You asked the Plan to waive the copayment for the TTE with contrast. You say that the testing was critical for 
your health. 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 $40 
copayment for diagnostic procedures and tests at an outpatient hospital.  
 
You have been asked to pay a $40 copayment for the TTE with contrast. The TTE with contrast 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 copayment for a transthoracic echocardiogram (TTE) with contrast provided on September 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychosocial rehab service provided on August 19, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for the psychosocial service. You say that you do not agree with this denial and want 
to dispute it. The Plan denied your request. The Plan says the provider is not a network provider and services 
were not referred by a network provider, 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 the psychosocial rehab service provided on August 
19, 2021, by an out-of-network provider.