Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from July 
22, 2021, to August 13, 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 the claims cannot be provided and paid without the Health Insurance Prospective Payment 
System/Resource Utilization Group (HIPPS/RUG) codes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 
 
This skilled nursing facility claim was not billed an appropriate HIPPS or RUG code. This is required in this 
case. 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 pay for skilled nursing facility (SNF) services provided 
from July 22, 2021, to August 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a hip replacement procedure and 
occupational therapy (OT) services provided on September 8, 2021. 
 
You asked the Plan to waive the copayments for the hip replacement and OT services. You say that you should 
have been under inpatient status instead of outpatient. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient surgery. Your contract with the Plan clearly says that you must pay a $20 copayment for each occupational therapy 
visit. 
 
You have been asked to pay a $150 copayment for the hip replacement. The hip replacement falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. You have also been asked to pay a $20 copayment for the occupational therapy 
services. The occupational therapy services fall within the Outpatient Rehabilitation Services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. Please 
note that to be considered as an inpatient, a written order from the provider needs to be submitted. There is no 
evidence in the file indicating that this order was written. 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 
copayments for a hip replacement procedure and occupational therapy (OT) services provided on September 8, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visit provided on May 20, 2021. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is included in the 
global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery.  
 
We looked at the file and Medicare rules. The requested visit is included in the global surgery payment for the 
procedure (62270) provided on the same date of service. Based on this information, we decided that Medicare 
rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for 
the visit provided on May 20, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from 
August 23, 2021, to September 13, 2021. 
 
You asked the Plan to pay for the services. You say that you are having an ongoing issue with these claims. 
The Plan denied your request. The Plan says that the patient-driven payment model (PDPM) code submitted is 
inconsistent with what was approved by the plan on the authorization. 
 
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. The plan has not substantiated their denial in this case. The plan has not given 
clear information on what parts of the authorization and the services rendered are not matching in this case. The 
plan's denial is vague and does not give enough information to the provider to correct their claim if needed. 
Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 23, 2021, to September 13, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 23, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 physician's services provided on February 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on October 10, 2021. 
 
You asked the Plan to pay for the drugs. You say that the medications given to you while you were in pain 
should be covered under the plan. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 self-administered drugs received 
on October 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hetlioz 20 mg capsule. 
 
You asked the Plan to pre-approve Hetlioz. You say that this is medically necessary for the enrollee's condition. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
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 Hetlioz 20 mg capsule.  
 
 
 
 Benefits for Hetlioz 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (tens) device 
((E0730) provided August 12, 2021. 
 
You asked the Plan to pay for the TENS device. You say that please review attached medical records as 
support of medical necessity. The Plan denied your request. The Plan says a TENS device, including supplies, 
for neuromuscular reconditioning is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pay for 
transcutaneous electrical nerve stimulation (tens) device ((E0730) provided August 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skin biopsy procedure performed on 
November 5, 2021. 
 
You asked the Plan to waive the copayment for the skin biopsy. You say that you feel the charges seem out of 
proportion for the procedure. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 
copayment for each outpatient hospital visit.  
 
You have been asked to pay $172.98, which is less than the $260 copayment for the skin biopsy. The skin 
biopsy is considered a surgical procedure and 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 a skin biopsy procedure performed on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the information provided does not satisfy the coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a total knee arthroplasty is subject to the coverage 
criteria listed 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 a total knee arthroplasty. Our reviewer 
says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found 
specifically, there is no imaging showing advanced degenerative joint disease of the knee joint. More info is 
needed before coverage can be approved. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty (27447).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a tildrakizumab 1mg injection (J3245) 
provided on July 8, 2021, and August 5, 2021. 
 
You asked the Plan to waive the coinsurance for the tildrakizumab 1mg injection. You say that the services 
should be covered as you were not made aware of the coinsurance beforehand and cannot afford to pay. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on 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 you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 You have been asked to pay a 20% coinsurance for two tildrakizumab 1mg injections ($4,964.00). 
Tildrakizumab 1mg injection fall 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 a tildrakizumab 1mg injection (J3245) provided on July 8, 2021, 
and August 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas device therapy provided on September 7, 2021 
and billed with CPT codes 96372, 97112, 97016, J3490, J3411, J3415, J7999 and 97139. 
 
You asked the Plan to pay for the Sanexas device therapy. You say that you would like reconsideration because 
the Sanexas device therapy was medically necessary. The Plan denied your request. The Plan says Medicare 
does not cover Prolotherapy. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Sanexas device therapy have not been met.  
 Specifically, with review of the file and publicly available records, we find that the physical therapy services at 
issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of 
Oklahoma. Additionally, the record does not contain documentation of the dosage and type of drug 
administered in each injection, which is required by Medicare for these services to be reimbursed. Therefore, 
we decided that the Plan does not have to pay for the Sanexas device therapy provided on September 7, 2021 
and billed with CPT codes 96372, 97112, 97016, J3490, J3411, J3415, J7999 and 97139.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $325 copayment charged for each ambulance transport 
provided on April 5, 2021, April 23, 2021, and April 26, 2021. 
 
You asked the Plan to waive these copayments. You say that each transport was medically necessary. The Plan 
denied your request. The Plan says each transport was covered however the cost share is your contractual 
copayment for each service. 
 
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 $325 
copayment for each one-way transport. The Plan paid its share of each transport. The $325 copayment for each 
transport is your contractual responsibility. 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 $325 copayment charged for each ambulance transport 
provided on April 5, 2021, April 23, 2021, and April 26, 2021.  
 
Please be advised the Plan stated you reached your out-of-pocket maximum with the last date of service in 
question by $75. Therefore, you are not being charged the $325 copayment for April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the external mobile cardiovascular 
telemetry with electrocardiographic recording (93228) provided on September 17, 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 service 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 you must pay a $20 
copayment per visit for laboratory services, non-radiological diagnostic tests, flat film x-rays, and ultrasounds.  
 
 You have been asked to pay a $20 copayment for the non-radiological diagnostic test 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 external mobile cardiovascular telemetry with 
electrocardiographic recording (93228) provided on September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transfer bench for tub or toilet with or without commode 
opening (E0247) purchased August 26, 2021. 
 
You asked the Plan to pay for transfer bench for tub or toilet. You say that you do not have the ability to get in 
the bathtub due to a hip fracture. The Plan denied your request. The Plan says bathtub lifts and bathtub sears 
are not covered because they are considered a convenience item and hygienic equipment and not primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for transfer bench for tub or toilet with or without commode opening 
(E0247) purchased August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80048, 84703) provided on September 9, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the ordering physician's office failed to obtain a 
referral for the denied service. 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 has also determined 
that these services are not urgent or emergent, nor were 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 laboratory services (80048, 84703) provided on 
September 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on August 10, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary and 
billed correctly. The Plan denied your request. The Plan says the enrollee was inpatient at the time services 
were rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code reported must reflect the setting in 
which the service was received.  
 
We looked at the file and Medicare rules. This claim was billed with POS code 22, for outpatient hospital. 
However, the documentation supports that the enrollee was admitted to inpatient status on August 9, 2021, 
through August 11, 2021. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services provided on August 10, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Testopel 75mg implant pellets. 
 
You asked the Plan to pre-approve Testopel 75mg implant pellets. You say that the requested Testopel 75mg 
implant pellet is medically necessary. The Plan denied your request. The Plan says that the enrollee must try 
and fail testosterone enanthate and testosterone topical gel and solution first. 
 
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 Testopel 75mg implant pellets. Our 
reviewer says that the requested Testopel 75mg implant pellet is medically necessary. Our physician reviewer 
found the record indicates that the enrollee has hypogonadism.  The record indicates that the enrollee has failed 
other treatments and has been receiving the requested medication for the past several years, most recently 
September 2021 and is due for every four month treatment.  The requested medication is not a new start.  The 
elements of the coverage criteria are satisfied.  The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Testopel 75mg implant pellets have been met. Therefore, we decided that the 
Plan has to pre-approve Testopel 75mg implant pellets.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 27, 2021. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on May 27, 2021.