Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on December 3, 
2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the doctor is in-network, and a 
referral is not required for a routine eye exam and refraction. You say that you were not diagnosed or treated 
for an eye condition. The Plan denied your request. The Plan says the claim reprocessed to apply a $40 
copayment for the eye exam. 
 
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 per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual 
glaucoma screening for members at high risk.   You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision Care" 
benefit category. The records show a medical eye exam was performed. 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 eye exam provided on December 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on April 19, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that another claim for a different date of service 
for the same procedure was partially paid The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered. The Plan also 
says that regarding the appellant's statement that the Plan paid for similar services rendered on a different date 
of service, they reviewed their records and determined that was due to an administrative error. 
 
 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 therapeutic exercises (97110) provided on April 
19, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90832) provided on August 9, 2021, to 
August 23, 2021, by an out-of-network (OON) provider. 
 You asked the Plan to pay for psychotherapy. You say that you were originally told no authorization was 
required, and upon checking the status of the claims, you saw they were denying for no authorization. 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. 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 psychotherapy (90832) provided on August 9, 
2021, to August 23, 2021, by an out-of-network (OON) provider.  
 
Your complaint about potentially being told you were given false information and the potentially being 
transferred various times to get authorization 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on September 17, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the facility staff to 
verify eligibility and obtain authorization from the enrollee's insurance company. The Plan denied your request. 
The Plan says no prior authorization was obtained. 
 
 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on September 17, 2021, by an out-
of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy sessions provided on September 29, 
2021, to September 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy sessions. You say that you have sent the medical records to 
support the medical necessity to treat the enrollee. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no approved authorization. Also, the services 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 physical therapy sessions provided on 
September 29, 2021, to September 30, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic ultrasound. You say that this is a routine service, 
and it is supposed to be covered. The Plan denied your request. The Plan says the service is a covered benefit, 
and the proper copayment 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 $155 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physician's office or at a free-standing facility. The total amount allowed for the date of service was $54.80 
which is less than the $155 copayment. Therefore, only $54.80 was charged as the copayment. You have been asked to pay a $54.80 copayment for the diagnostic ultrasound. The diagnostic ultrasound 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 diagnostic ultrasound provided on November 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that home health aide services are 
medically necessary. The Plan denied your request. The Plan says home health aide services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that home health aide services are not medically reasonable and necessary. Our physician 
reviewer found that you had a personal care/functional assessment on August 18, 2021. The assessment showed 
that you need 22.5 hours per week to help you. You have been receiving Home Health Aide (HHA) 8 hours per 
day.  HHA must be part-time or intermittent. You have been approved for agency Personal Care (PC), 
22.5 hours per week. Your needs can be met with this service. The review has determined that home health 
aide services are not reasonable and necessary to the treatment of your illness or injury by the skilled 
professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on April 22, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the psychotherapy. You say that you rendered treatment to the patient in good 
faith that the service would get reimbursed. The Plan denied your request. The Plan says the services were 
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 psychotherapy provided on April 22, 2021, by 
an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on November 9, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for injections. You say that appealing claim payment denial for services rendered to 
your member. The Plan denied your request. The Plan says the care was not approved in compliance with the 
health plan's authorization procedures. 
 
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 injections provided on November 9, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory service for oncology provided on December 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service for oncology. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory service for oncology provided on December 23, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for fulphilla injections provided on 
November 14, 2021, and December 5, 2021. 
 
You asked the Plan to reduce the coinsurance for fulphilla injections. You say that you need to have this 
injection to replace white blood cells that have been removed by the chemotherapy infusion. You also say that 
the provider told you it would only be a $45 copayment but are being billed $506. 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 20% 
coinsurance for part B drugs.  The record shows the claims have been processed correctly. You have been asked to pay $506.84, which is 
20% of the allowed amount for each fulphilla injection on November 14, 2021, and December 5, 2021 
($2,534.22 allowed amount x % coinsurance = $506.84). You have been asked to pay a total of $1,013.68 
($506.84 + $506.84 = $1,013.68). Fulphilla injections 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 reduce the coinsurance for fulphilla injections provided on 
November 14, 2021, and December 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
15, 2021, to July 19, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you had to return less 
than 48 hours after your first stay. You say that they should be considered one stay. 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 $250 per 
day for days 1-5 and $0 per day for days 6-90 for each inpatient admission.  
 
The file shows that you were admitted to the hospital from July 15, 2021, to July 19, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $250 per day for the first 4 days of inpatient hospital care. The total for your stay is $1,000 ($250 copayment x 4 days = $1,000). The inpatient 
hospital care falls within the Inpatient Hospital 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 inpatient hospital care provided from July 15, 2021, to July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 September 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for combination use of Keytruda and Mvasi. 
 
You asked the Plan to pay for Keytruda and Mvasi. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of payment for these drugs is correct, because this 
combination was not appropriate for the clinical scenario. 
 
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 pay for Keytruda and Mvasi. Our reviewer says that 
these drugs do not meet the Medicare criteria for payment. Our physician reviewer found Keytruda and Mvasi 
are not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This use is not supported by 
one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda and Mvasi have not been met. Therefore, we decided that the Plan 
does not have to pay for combination use of Keytruda and Mvasi.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid provided on April 6, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that the patient has profound hearing loss and needs 
hearing aids. You say that the Plan covers $2,000 every 2 years and you do not want to take the hearing aids 
back. The Plan denied your request. The Plan says hearing aids are excluded from coverage. 
 
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 2 
hearing aids every 2 years from the Plan's hearing aid vendor.  
 
 
  We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Specifically, hearing aids must be purchased from the Plans 
hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aid provided on 
April 6, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for total shoulder arthroplasty revision services (procedure code 23473) 
provided to the enrollee on February 5, 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 that this procedure requires that a qualifying service or procedure be received and covered. 
 
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 23473 is "Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid 
component." 
 
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 supported by the medical records. Our reviewer found the procedure details indicate that a 
revision of the reverse total shoulder has been provided. A portion of the implants were indicated to have been 
revised in size. Therefore, the records do support revision of total shoulder arthroplasty, including allograft 
when performed, humeral or glenoid component (CPT 23473). 
 
We looked at this coder's review, the file, and Medicare rules. CPT 23473 was supported for date of service 
2/5/21. The plan has not substantiated their denial. Based on this information, we decided that Medicare rules 
for coverage of the services have been met. Therefore, we decided that the Plan has to pay for total shoulder 
arthroplasty revision services (procedure code 23473) provided to the enrollee on February 5, 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.