Persius/hicric huggingface dataset:
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 
November 30, 2021, to December 14, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
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, there was no 
admission diagnosis on the claim. This means the claim is not payable as billed. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from November 30, 2021, to 
December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
November 3, 2021, through November 9, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that each time you are 
admitted to an acute care hospital you must pay $200 per day, for days 1-5 and $0 after day 5.  
 
You have been asked to pay $1,000 ($200 x 5 days) for the inpatient hospital care provided. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care 
provided from November 3, 2021, through November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0210) provided on March 30, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 24, 2021. 
Therefore, we decided that the Plan does not have to pay for intraoral x-rays (D0210) provided on March 30, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided from November 2, 2022, to 
November 4, 2020. 
 
You asked the Plan to pay for the hospital services. You say that the claim was filed within the 18-month filing 
timeframe. The Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital services was not filed until March 1, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the hospital services provided from November 2, 2022, to November 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to preapprove a second opinion office visit at an out-of-network provider. 
 
You asked the Plan to preapprove a second opinion office visit. You say that this out-of-network provider has 
experts that treat Waldenstrom's Macroglobulinemia (WM) which is a rare type of uncurable cancer. You also 
say that you were misdiagnosed for five years and want to see this provider because of the expertise with your 
rare type of cancer. The Plan denied your request. The Plan says that they have no contractual obligation to 
refer you to a non-plan provider when appropriate care and service is available within network with Plan 
providers. The Plan also says that they denied the request for services with non-contracted provider because the 
provider is not credentialed nor contracted with the Plan and the services are available in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 preapprove a second opinion office visit. Our 
reviewer says that this meets criteria. Our physician reviewer found this patient has not undergone any 
treatment and continues to suffer symptoms that may be related to WM. Our physician reviewer also found that 
WM is a rare disorder and has no standard treatment, and knowing when and how to treat can be difficult. Our physician reviewer also found that clinical trials are recommended. Our physician reviewer also found that 
no providers have been indicated from the Plan or surrounding affiliated network. 
 
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 second opinion office visit have been met. Therefore, we decided that the Plan 
has to preapprove a second opinion office visit at an out-of-network provider.  
 
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 pay for the critical care services provided from February 11, 2022, to 
February 13, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that the time-based CPT code 99291 is not 
supported in the medical record. Specifically, the medical records do not indicate the amount of time spent on 
the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of the 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care 
services provided from February 11, 2022, to February 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99292) provided on March 10, 2022. 
 
You asked the Plan to pay for critical care services (99292). You say that 99292 is an exception to the 
standalone rule and can be billed on separate claims due to different providers rendering services during the 
same 24 hours. You say that the claim should be processed accordingly. The Plan denied your request. The 
Plan says only providers of the same specialty and group can bill codes 99291 and 99292 on the same day. 
  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, we have confirmed that code 99292 
is an add-on code and has not been billed with an appropriate primary procedure code by a provider with the 
same specialty. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care services (99292) provided on March 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs, Ciprodex and oxymetazoline, 
provided in an outpatient setting on February 9, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the drugs administered during surgery 
were deemed necessary by the surgeon for the surgery to be successful. You also say that you feel these should 
be paid for. The Plan denied your request. The Plan says the drugs you received in the outpatient setting are 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs, 
Ciprodex and oxymetazoline, provided in an outpatient setting on February 9, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on December 27, 
2021. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you were told that insurance would 
cover the cost of COVID-19 test kits. You also say that you were not advised that a doctor's order was 
necessary. The Plan denied your request. The Plan says these tests are not covered. The Plan also says that 
Medicare will not provide payment for OTC COVID-19 tests obtained prior to April 4, 2022. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 tests is an OTC item. While Original Medicare started covering these tests on April 4, 2022, 
Medicare Advantage plans are able to elect to provide a supplemental benefit for this or elect not to do so. 
Therefore, we decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on 
December 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on June 23, 2021, and 
June 24, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you have both Medicare Part B and 
Part D, and you believe these drug charges should have been paid. The Plan denied your request. The Plan says 
these drugs may be payable under Medicare Part D, but are not payable under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on June 23, 2021, and June 24, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the enrollee has an overactive bladder and urge 
incontinence. You say that the enrollee failed Myrbetriq and had favorable results with Gemtesa combined with 
Ditropan. The Plan denied your request. The Plan says drug coverage is limited to drugs covered under the 
medical benefit. The enrollee's Medicare Advantage Plan does not cover outpatient prescription drugs. The 
enrollee has TRS-CARE MA which provides its own pharmacy benefits. The Plan says that the enrollee's 
prescription coverage is provided through CVS Silverscript. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.   
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says reasonable amount of time has been given to 
perform/learn home exercise programs and no evidence showing that further physical therapy will improve 
your health condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that there is no evidence unique skills of a therapist are necessary to 
achieve a home exercise program (HEP). The enrollee had reached functional goals in March. The record fails 
to show why additional therapy from a skilled therapist is needed to achieve independence with HEP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 physical therapy visits.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on November 
9, 2021. 
 
You asked the Plan to pay for the hospital care. You say that documents for proof of timely filing have been 
provided. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 2, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99232) provided on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on December 22, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied 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 $45 
copayment for an office visit.  
 
You have been asked to pay a $45 copayment for an office visit. An office visit falls within the 
Physician/Practitioner services, including doctors office visits 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 office visit on December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospitalization beyond 
August 4, 2022. 
 
You asked the Plan to pre-approve a continued inpatient psychiatric hospitalization. You say that you would 
like authorization for services rendered in good faith. The Plan denied your request. The Plan says the enrollee 
did not meet the criteria for continued psychiatric hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 
 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 continued inpatient psychiatric 
hospitalization. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient 
psychiatric care beyond August 4, 2022. Our physician reviewer found it was not expected this enrollee would 
improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal 
ideation, auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any 
acute threats to safety. Our reviewer also found it did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care. 
 
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 continued inpatient psychiatric hospitalization have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospitalization beyond 
August 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional transcranial doppler study of the intracranial 
arteries (93886) provided on December 1, 2021. 
 
You asked the Plan to pay for the additional transcranial doppler study. You say that you would like this claim 
to be reconsidered for payment. The Plan denied your request. The Plan says the records submitted do not 
indicate that two separate services were performed/supported. 
 
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 93886 is transcranial doppler study of the intracranial 
arteries; complete study. 
 
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 additional transcranial doppler study. Our reviewer says 
that the additional transcranial doppler study of the intracranial arteries is not supported in the medical records 
Our reviewer found the records show a single transcranial doppler was done on December 1, 2021. 
 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional transcranial doppler study have not been met. Therefore, we 
decided that the Plan does not have to pay for the additional transcranial doppler study of the intracranial 
arteries (93886) provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
October 22, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 22, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the deductible and the coinsurance for an office visit with an excision of 
lesion of tongue with closure provided on February 17, 2022. 
 
You asked the Plan to waive the deductible and the coinsurance for an office visit with an excision of lesion of 
tongue. You say that your explanation of benefits (EOB) says there is no deductible or copayment for this, so 
there should not be a bill. The Plan denied your request. The Plan says that because you get assistance from the 
Medicaid program with your Medicare Part A and Part B cost sharing, you may pay nothing for your Medicare 
health care services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that you must pay $0 cost sharing amount for each Medicare-covered office visit 
and a $0 cost sharing amount for each Medicare-covered outpatient surgery.  
 
The Plan says you must pay a $77.97 deductible and $50.24 coinsurance amount for an excision of lesion of 
tongue. The Plan also says you must pay $17.62 coinsurance for an office visit. Based on the Plan contract, 
however, you cannot be asked to pay more than the $0 cost sharing amount per contract for an office visit with 
an excision of lesion of tongue. Therefore, we decided that the Plan has to waive the deductible and the 
coinsurance for an office visit with an excision of lesion of tongue with closure provided on February 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.