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

 
We decided that the Plan does not have to pay for office visit provided on May 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 office visit provided on May 17, 2022, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for an inflimixab-axxq (AVSOLA) injection provided to the enrollee on 
May 17, 2022. 
 
You asked the Plan to pay for the injection. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this is not covered for the diagnosis listed on the claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 injection. Our reviewer says that the 
injection at issue in this case was medically reasonable and necessary. Our physician reviewer found that this 
drug is a standard of care for the treatment of immunotherapy-induced diarrhea refractory to steroids. This use 
is supported by the National Comprehensive Cancer Network 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 injection have been met. Therefore, we decided that the Plan has to pay for 
an inflimixab-axxq (AVSOLA) injection provided to the enrollee on May 17, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for self-administered drugs on May 25, 2022, 
to July 29, 2022. 
 
You asked the Plan to waive the copayment for self-administered drugs. You say that you would like to appeal 
the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for self-administered drugs.  
 
You have been asked to pay a 20% coinsurance for self-administered drugs. This item/service falls within the 
home infusion therapy 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 self-
administered drugs on May 25, 2022, to July 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 29, 
2022, through March 31, 2022. 
 
You asked the Plan to pay for these services. You say that the inpatient hospital care provided was medically 
necessary for the enrollee. The Plan denied your request. The Plan says the inpatient hospital care provided was 
not medically necessary. 
 
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 these services.  Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the enrollee tested positive for COVID-19 on March 23, 2022. He did 
not become symptomatic until March 29, 2022 with a cough. The nursing home facility did not have isolation 
capability, so he was transferred to the hospital for continued care and treatment. On March 29, 2022 the 
enrollee was asymptomatic from a COVID standpoint, with no oxygen requirements. He was given intravenous 
fluid and intravenous antibiotics, reportedly for a urinary tract infection. The enrollee remained 
hemodynamically stable. Tests including multiple chest x-rays, computed tomography (CT), and venous 
doppler testing, all did not reveal any significant findings. His oxygen saturation levels remained stable. He 
remained on room air without the need for supplemental oxygen. His respiratory rate remained stable. The 
enrollees vital signs were stable. A computed tomography scan of the lower extremity did not show any 
evidence of osteomyelitis or soft tissue abnormality. There was no documentation of the need for hospital 
services. There was no physician notation indicating the medical necessity of requiring hospital services for a 
period of two midnights. The review indicates that the record did not show that at the time of the inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier ED 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from March 29, 2022, through March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids and supplies provided on June 10, 2022. 
 
You asked the Plan to pay for the hearing aids and supplies. You say that you are eligible for a reimbursement 
up to $750. The Plan denied your request. The Plan says the benefit maximum for the services was met. 
 
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 up to $750 for Plan members.  
 
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 hearing aids and supplies have not been met. Specifically, the Plan paid the $750 towards the 
hearing aids on this date of service. Therefore, we decided that the Plan does not have to pay for the hearing 
aids and supplies provided on June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 
20, 2022, to June 21, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are requesting a 
reconsideration. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $298 
copayment per day for days 1 to 5 for in-network Inpatient hospital care.  
 
You have been asked to pay a $298 copayment per day for days 1 to 5 for inpatient hospital care. The total 
allowed amount is $596 (298 x 2 days = 596). However, you are only being asked to pay $298 which is less 
than the required amount. 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 June 20, 2022, to June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab testing on April 15, 2022. 
 
You asked the Plan to waive the coinsurance for lab testing. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for genetic testing. Covered services include but are not limited to laboratory tests. The provider 
billed in the amount of $2,995 and the allowed amount is $760. $760 x 20% = $152. Therefore, results in the 
total cost sharing amount of $152. 
 
You have been asked to pay a 20% coinsurance for lab testing. This item/service 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 
coinsurance for lab testing on April 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 25, 2022. 
 
You asked the Plan to pay for the medical services. You say that your organization provided medically 
necessary services in good faith. The Plan denied your request. The Plan says it is not responsible for this bill 
because the member was on hospice on the date of service. 
 
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 medical services provided on April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the gauze (code A6219-A1) billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for code A6219-A1. You say that this code is a separately payable supply. The Plan 
denied your request. The Plan says that code A6219 has a status indicator of P on the Medicare Physician Fee 
Schedule Database (MPFSDB) File, which means it is always bundled and no separate payment is made. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for its denial is that code A6219 is not 
separately payable because it has a status indicator of P on the MPFSDB.  While code A6219 may have that 
status indicator, the MPFSDB is not applicable here.  This item is not being billed by a physician/practitioner.  
It is being billed by a durable medical equipment (DME) vendor.  The DME fee schedule applies here, and 
there is no such payment policy applicable to code A6219 under the correct DME fee schedule.  The Plan has 
offered no other support or provided any other documentation that would substantiate its denial. Therefore, we 
decided that the Plan has to pay for the gauze (code A6219-A1) billed for date of service February 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) and sales tax (S9999) provided on 
June 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids and sales tax. You say that you would like to be reimbursed for 
the hearing aids. The Plan denied your request. The Plan says hearing aids are not covered when purchased 
OON. 
 
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 ordered through the Plans specified hearing vendor, 
 
We looked at the file and the Plan's rules. In this case the hearing aids were not ordered through the Plans 
hearing vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids and 
sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids 
(V5298) and sales tax (S9999) provided on June 28, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammogram provided on May 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a mammogram. You say that this should be covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 mammogram provided on May 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 29, 2021, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. 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 office visit provided on October 29, 2021, by 
an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services provided from February 9, 2022, 
to February 23, 2022. 
 
You asked the Plan to pay for the behavioral health services. You did not provide a specific argument with 
your appeal request. The Plan denied your request. The Plan says it is not responsible for this claim because the 
member was enrolled in hospice on the dates of service at issue. 
 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 behavioral health services provided from February 9, 2022, to 
February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no mention of syncope. 
 
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 that while the patient has a history of atrial flutter, there is no documentation provided to suggest a 
history of unexplained syncope or any other apparent indication for an implanted loop recorder (ILR). In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
patient'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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a subcutaneous cardiac rhythm monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with a pathologist provided on May 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON pathologist services. You say that you needed a COVID-19 test, so this 
service should be covered. The Plan denied your request. The Plan says these OON services were not 
authorized.  Multiple attempts to get medical records to substantiate an authorization were unsuccessful. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that the Plan requires prior authorization for physician/practitioner services.  You did not have prior 
authorization for the services in dispute. Therefore, we decided that the Plan does not have to pay for the office 
visit with a pathologist provided on May 11, 2022, 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 endoscopy provided on July 05, 2022. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you never had to pay this in the past 
so you shouldnt have too now. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $300 copayment for endoscopy. This item/service 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 endoscopy provided on July 05, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet the conditions for a stay in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that the enrollee has complex functional impairments however, evaluating therapy notes show that the enrollee has had poor participation in physical 
and occupational therapy. Additionally, there is no documentation to show that the enrollee has active 
comorbidities that would require close medical monitoring on an inpatient basis in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.