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

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 13, 2021. 
 You asked the Plan to pay for the eye refraction. You say that you had a complete eye exam a few days before, 
and only went to the optometrist for a refraction because your first provider does not provide this service. You 
felt it was unnecessary to have a second eye exam provided with this service. The Plan denied your request. 
The Plan says eye refractions are not covered by Original Medicare and are only covered by the Plan's 
supplemental benefit as part of a complete routine eye exam. In this case, you received only an eye refraction, 
and it was not provided as part of a routine eye exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided as part of a complete routine vision exam. 
 
We looked at the file and the Plan's rules. The Plan does not list eye refractions as covered when they are 
provided as the sole service. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
(92015) provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 27, 2021. 
 You asked the Plan to pay for the services provided. You say that the test was medically necessary. The Plan 
denied your request. The Plan says there is a more appropriate code to report this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The claim shows that the testing at issue was billed with codes 88346 and 
88350. We find that the testing was not billed with the appropriate code per the guidelines. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the hospital bed. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says based on the records provided, there is no medical need 
for a semi-electric hospital bed. The enrollee does meet the criteria for a fixed height hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided and the provided certificate of medical necessity there is 
documentation that the enrollee needs the head of the bed greater than 30 degrees due to a history of skin ulcers 
and her chronic obstructive pulmonary disease. There no is documentation that the enrollees condition requires 
special attachments that cannot be fixed and used on an ordinary bed. As the provided certificate of medical 
necessity does not document that the enrollee requires frequent changes in body position or immediate changes 
in body position, the semi-electric hospital bed does not meet Medicare criteria for medically necessary for this 
enrollee. Records do document necessity for a fixed height hospital bed however. 
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve semi-electric hospital bed (E0260).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DIEP procedure to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that these services can be provided in-network. 
 
  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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the DIEP procedure to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 14, 2021. 
 
 
 
 You asked the Plan to pay for the lab services. You say that this drug testing was medically necessary. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.  The records 
show that the specimen was collected from the patient in an office setting on September 14, 2021, and it was 
received by your lab on September 16, 2021.  You have incorrectly listed September 14, 2021, as the date of 
service and you have incorrectly stated that the place of service is 81. 
 
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 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray examination of the foot (73630) provided on 
October 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray examination of the foot. 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. 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 an x-ray examination of the foot (73630) provided 
on October 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Injection on April 9, 2021. 
 
You asked the Plan to waive the coinsurance for an Injection. You say that the charge was untimely. The Plan 
denied your request. The Plan says the 20% coinsurance you are being charged is correct. 
 
 
 
 
 
 
 
 
 
 
 
 
 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 an Injection. The allowed amount of the injection is $1,024.80, resulting in a coinsurance 
amount of $204.96. 
 
You have been asked to pay 20% coinsurance for an Injection. An Injection falls within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an Injection on 
April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Eye surgery on April 13, 2021. 
 
You asked the Plan to waive the copayment for Eye surgery. You say that you are requesting reconsideration of 
your responsibility to pay the copayment The Plan denied your request. The Plan says the copayment you are 
being charged is correct. 
 
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 $200 
copayment for Eye surgery.  
 
 
 
 
 
 
 
 You have been asked to pay a $200 copayment for Eye surgery. 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 Eye surgery on April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
July 16, 2021, to July 20, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you would like the 
copayment to be waived. The Plan denied your request. The Plan says 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 $225 
copayment for per day for Days 1-5 and the day before you are discharged is your last inpatient day. The total 
copayment amount charged was $900 ($225 copayment a day x 4 days). 
 
  You have been asked to pay a $900 copayment for an inpatient hospital stay. an inpatient hospital stay falls 
within the per day for Days 1-5 and the day before you are discharged is your last inpatient day 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 inpatient hospital stay provided from July 
16, 2021, to July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 28, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was seen by an in-network 
physician who sent for the laboratory work. The Plan denied your request. The Plan says both the rendering 
and referring providers are both out-of-network providers and there was no 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 laboratory services provided on January 28, 
2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
19, 2021 to June 12, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the initial Request for Anticipated 
Payments (RAP) claim was not received within 5 calendar days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that that all Home Health Agencies (HHAs) must 
submit a request for anticipated payment (RAP)within 5 calendar days after the start of care date for initial 30-
day periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which 
is set at 0 percent at the beginning of every 30-day period. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
indicates the RAP was not submitted within 5 days of the from the start of care date, May 19, 2021.  Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from May 19, 2021 to June 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided June 
28, 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 and meet all applicable professionally recognized standards of 
healthcare. 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 June 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Ultrasound on September 17, 2021. 
 
You asked the Plan to waive the copayment for an Ultrasound. You say that the insurance portal indicates that 
you have a $0 copay. The Plan denied your request. The Plan says the copayment you are being charged is 
correct. 
 
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 an Ultrasound.  
 
You have been asked to pay a $155 copayment for an Ultrasound. An 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 an Ultrasound on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vision services. 
 
You asked the Plan to pre-approve vision services. The Plan denied your request. The Plan says the 
documentation indicates that the member received glasses on November 1, 2021, therefore, the member 
is not eligible for her vision benefit until November 1, 2022 as per the Plans Evidence of Coverage. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services every year. 
 
We looked at the file and the Plan's rules. The file shows you received glasses on November 1, 2021, and you 
are not eligible for vision benefits until November 1, 2022. Based on this information, we decided that the 
Plan's rules for coverage of vision services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vision services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary Our physician reviewer found the enrollee has retinal vein occlusion 
with retinal edema. He has not tried and failed the Plan's required drug, Avastin. The records do not show that 
the required drug would be contraindicated or less effective; therefore, Eylea is not reasonable or medically 
necessary. 
 
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 pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from July 9, 2020 to 
July 19, 2020. 
 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 submitted records do not support the billing of diagnosis code A41.9. She was 
admitted for the evaluation and management of Coumadin toxicity, receiving Vitamin K and fresh frozen 
plasma. She received empiric antibiotics for cystitis/urinary tract infection. Blood culture returned with growth 
of Alpha-hemolytic Streptococcus. Urine culture was without growth. There was no documentation of clinical 
or laboratory evidence for sepsis. The records do not support the billing of diagnosis code A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9 (sepsis, unspecified 
organism). 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 submitted records do not support the billing of diagnosis code A41.9. Our physician reviewer found the 
enrollee presented for evaluation of right flank pain.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services rendered from July 9, 2020 to July 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full coverage for hearing aids for both ears. 
 
You asked the Plan to pre-approve full coverage for hearing aids. You say that the hearing aids are medically 
necessary, and you cannot afford the cost. The Plan denied your request. The Plan says you have a $100 
maximum allowance towards hearing aids. 
 
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 up to a $100 maximum allowance every year.  
 
We looked at the file and the Plan's rules. The Plan contract clearly states that hearing aids will be covered up 
to a $100 allowance. Therefore, we decided that the Plan does not have to pre-approve full coverage for 
hearing aids for both ears.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacro-iliac joint 
(SIJ) provided on October 27, 2021. 
 
You asked the Plan to pay for the RFA of the SIJ. You say that this should be covered due to medical necessity. 
The Plan denied your request. The Plan says this service is considered experimental and noncovered. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA of the SIJs is considered 
experimental/investigational at this time.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the RFA of the SIJ have not been met. Therefore, we decided that the Plan does not have to pay for 
the radiofrequency ablation (RFA) of the sacro-iliac joint (SIJ) provided on October 27, 2021.