Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the otolaryngology services provided on February 25, 2022. 
 
You asked the Plan to pay for the services provided. You say that the provider is enrolled with Medicare. The 
Plan denied your request. The Plan says that the provider is not eligible to be paid. 
 
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. 
 
We looked at the file and the rules. The provider at issue is eligible to provide services under Original 
Medicare. The billing provider is also eligible to provide services under Original Medicare. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request. Therefore, we decided that the Plan has to pay for the otolaryngology services provided on 
February 25, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a diphenhydramine and rituximab-pvvr, 
biosimilar injections provided on July 16, 2021. 
 
You asked the Plan to waive the coinsurance for a diphenhydramine and rituximab-pvvr, biosimilar injections. 
You say that you made several calls concerning this bill and was advised not to pay it. The Plan denied your 
request. The Plan says you have been charged the correct coinsurance amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
 
 
  
You have been asked to pay a total of $749.95, which is 20% of the allowed amount for the injections. 
  
Service Allowed Amount Coinsurance Member Liability 
diphenhydramine hcl .95 20% .19 
rituximab-pvvr, biosimilar $3,623.84 20% $724.77 
rituximab-pvvr, biosimilar $124.96 20% $24.99 
TOTAL:   $749.95 
  
The diphenhydramine and rituximab-pvvr, biosimilar injections 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 diphenhydramine and 
rituximab-pvvr, biosimilar injections provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 25, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are 
included in the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility of 
the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the application of vein wound compression 
bandages performed on February 11, 2022. 
 
You asked the Plan to waive the copayment for the application of vein wound compression bandages. You say 
that this cost share is too high, and you should only be responsible for a $30 copayment. The Plan denied your 
request. The Plan says you are responsible to pay a $139.10 copayment for in-network outpatient surgery 
performed on February 11, 2022. 
 
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 $295 
copayment for Outpatient Surgery and Other Medical Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $139.10 copayment for in-network outpatient surgery. The application of vein 
wound compression bandages falls within the Outpatient Surgery and Other Medical Services Provided At 
Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. Your contract with the Plan 
clearly says that you must pay a $295 copayment for in-network outpatient surgery. However, you have only been asked to pay $139.10, which is less than the $295 copayment 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 the application of vein wound compression bandages performed on February 11, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that this testing will help the enrollee 
with depression and anxiety symptoms. The Plan denied your request. The Plan says the neuropsychological 
testing is not medically necessary because the enrollee's plan of care can be created without the results of this 
testing. 
 
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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the records indicate that the enrollee has had difficulty with depression 
and anxiety. Documentation shows this enrollee be pleasant able to tolerate the medication without difficulty. 
The enrollees documentation shows a patient health questionnaire score of 9 out of 17 and a GED score of 7 
out of 9. Utilizing the criteria from Interpol which says that this testing is intended to diagnose and characterize 
the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain including 
detection of neurologic disease based on quantitative assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central 
nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous system 
disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or management 
strategies among individuals with neuropsychiatric disorders, this enrollee does not meet the criteria as they are 
not showing severity of symptoms that would warrant this type of diagnostic treatment and is therefore not 
appear medically necessary or reasonable. The neuropsychological testing as outlined documentation is unclear 
the reasoning for the testing to be obtained as the provider would like to have the enrollee obtain GeneSight 
testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing evaluation services (96132).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 81455 provided on December 6, 
2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81455 is not covered because it is unlikely 
to impact therapeutic decision-making in the clinical management of the enrollee. 
 
We looked at the file and Medicare rules. The genetic testing rendered was billed with code 81455. This 
service is specifically not covered. Based on this information, we decided that Medicare rules for coverage of 
the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing coded 81455 provided on December 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the cervical spine (72125) 
and CT of the head or brain (70450) provided on December 28, 2021. 
 
You asked the Plan to pay for the CT of the cervical spine and CT of the head or brain. You say that you would 
like this claim to be reprocessed. 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 enrollees terminal 
condition. 
 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 December 21, 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 computed 
tomography (CT) of the cervical spine (72125) and CT of the head or brain (70450) provided on December 28, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on January 24, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the Medicare Advantage plan is the 
enrollee's primary plan. You also say that the services should be reprocessed and paid. 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. 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 the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on January 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on January 28, 2022, 
and March 11, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you were told to lower your plan and 
now your injections aren't covered like they used to be. You believe they should be covered because you were 
misguided. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs.  
 
 
 
 
 You have been asked to pay a total of $732.60 which is 20% of the allowed amount for the injections. The 
allowed amount is $1,831.50 (20% x $1,831.50= $366.30) ($366.30 x 2 injections= $732.60). Injections 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 injections provided on January 28, 2022, and March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
18, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that at your pre-op appointment 
you were told you would not have a copayment. The Plan denied your request. The Plan says the coinsurance 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 $5 
copayment for diagnostic lab services and diagnostic procedures and test (per day, per facility).  
 
You have been asked to pay $5 copayment for laboratory services. Laboratory services falls within the 
Outpatient Hospital Services 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 laboratory 
services provided on February 18, 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 you need inpatient rehabilitation to relearn to bathe, 
shower, and feed yourself. You say that you have multiple health issues and a risk of falling. The Plan denied 
your request. The Plan says based on Medicare guidelines, the inpatient rehabilitation services you requested 
do not meet all the requirements for approval. 
 
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 you were admitted for spinal surgery and was discharged to skilled nursing. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) provided on December 2, 2021. 
 
You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not supported by 
the documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the items were delivered on November 27, 2021; however, the date of service billed is December 2, 
2021. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic 
continuous glucose monitor (CGM) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on January 21, 2022. 
 
You asked the Plan to pay for infrared therapy. The Plan denied your request. The Plan says infrared therapy is 
considered not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act). 
 
We looked at the file and Medicare rules. Medicare says say that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. Based on this 
information, we decided that Medicare rules for coverage of infrared therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for infrared therapy provided on January 21, 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 skilled nursing is not helping you and you need 
the IRF services. The Plan denied your request. The Plan says the enrollee does not require an intensive, 
complex, multidisciplinary approach to daily therapy. There is no need for physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care 
such as at a skilled nursing facility, on an intermittent basis at home with home health care, or in a long-term 
care setting. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for lumbar spine surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 23, 2021. 
 
You asked the Plan to pay for the genetic testing. 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. Medicare rules say that tests that include the FANCC gene are non-
covered. 
 
We looked at the file and Medicare rules. Review of the file shows that this testing rendered included testing 
for the FANCC gene. This means the entire panel is not covered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing provided on December 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery provided on January 25, 2022. 
 
You asked the Plan to waive the copayment for surgery. You say that you do not believe you owe the $176.74 
that you are being billed by the provider. The Plan denied your request. The Plan says you have been charged 
the correct copayment 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 $250 
copayment for in-network surgery services at an outpatient hospital. 
 
You have been asked to pay $176.74, which is less than the $250 copayment for surgery. The 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 surgery provided on 
January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on January 
26, 2022. 
 
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the item billed is not supported by the 
documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the documentation does not sufficiently support the need for the 
billed supply code. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder 
elbow wrist hand orthosis provided on January 26, 2022.