Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hospital bed provided on April 26, 2022, 
and May 26, 2022. 
 
You asked the Plan to waive the coinsurance for the hospital bed. You say that you have never paid a 
coinsurance for anything. The Plan denied your request. The Plan says the cost-share has been unchanged since 
2020 and the proper coinsurance was applied for the equipment 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 the durable medical equipment and prosthetics/medical supplies. The total amount allowed for 
each date of service was $77.62 with a coinsurance for each date of $15.52 ($77.62 total amount x 20% 
coinsurance). The total coinsurance amount for both dates of service was $31.04 ($15.52 coinsurance amount x 
2 dates). 
 
  You have been asked to pay a $31.04 coinsurance for the hospital bed. The hospital bed falls within the 
Durable Medical Equipment and Prosthetics/Medical Supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a hospital bed provided on April 26, 2022, and May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
May 12, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you cannot afford to pay for 
these treatments. The Plan denied your request. The Plan says the copayment applied was 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 $350 
copayment for Outpatient Hospital Facility per date of service.  
 
You have been asked to pay a $350 copayment for outpatient surgery. Outpatient 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 outpatient surgery services 
provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochromatic tint (V2744), anti-reflective coating 
(V2750), U-V lens (V2755), and polycarbonate or equal lens (V2784) provided on May 2, 2022. 
 
You asked the Plan to pay for the enhanced lenses. You say that you thought these glasses were covered under 
your medical benefit. The Plan denied your request. The Plan says these lenses are not covered benefits. The 
Plan also says that these enhanced lenses were made available to you at a discounted rate. 
 
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 does not cover enhanced lenses. 
 
 
 
 We looked at the file and the Plan's rules. The lenses you received are enhanced lenses that are clearly stated as 
not being covered by the Plan, but you can purchase them for an additional cost to you. Based on this 
information, we decided that the Plan's rules for coverage of the enhanced lenses have not been met. Therefore, 
we decided that the Plan does not have to pay for the photochromatic tint (V2744), anti-reflective coating 
(V2750), U-V lens (V2755), and polycarbonate or equal lens (V2784) provided on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390) provided 
from March 1, 2022, to June 1, 2022. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you disagree with the 
coinsurance amount and that you have never paid this amount before. The Plan denied your request. The Plan 
says the coinsurance was assessed correctly according to your contract with the Plan. 
 
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 durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for an oxygen concentrator. Oxygen concentrators fall within 
the durable medical equipment (DME) and related supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan.  
 This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390) provided 
from March 1, 2022, to June 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care service provided on December 31, 2021. 
 
You asked the Plan to pay for critical care. You say that you are appealing with records which support the 
service originally billed. The Plan denied your request. The Plan says the records do not support the level of 
service billed on this claim. 
 
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 to 74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not include 
the duration of time spent with the patient to support the particular code billed on this claim. Based on this 
information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care service provided on December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on May 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says the services 
were provided out-of-network and were not 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 the outpatient visit provided on May 11, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (Q4038, 29405) provided on March 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable. 
 
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 find that payment for codes Q4038 and 29405 is not supported in the medical record. Specifically, code 
Q4038 returns OCE edit 62 due to status indicator B under OPPS. This edit indicates that this code is not 
recognized by the OPPS. This edit also denies all claims lines. As such, code 29405 is also not payable. 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 the services (Q4038, 29405) provided on March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on May 26, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you are being penalized because of the 
processing time of the May 23, 2022, claim which would have met your out-of-pocket expense. You say that 
the $180 copayment should be voided. The Plan denied your request. The Plan says the copayment applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 
copayment for advanced imaging services at an in-network primary care office, specialist office or freestanding 
radiological facility.  
 
 
  You have been asked to pay a $180 copayment for the MRI. The MRI 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 the MRI provided on May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the arthrocentesis and Orthovisc injection 
provided from May 12, 2022, through May 26, 2022. 
 
You asked the Plan to waive the cost for the arthrocentesis and Orthovisc injections. You say that you want to 
know why your cost more than doubled since your coverage didn't change. You say that follow-ups are part of 
the process, and you shouldn't have a copayment. The Plan denied your request. The Plan says the claims 
processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 19% 
coinsurance for Medicare Part B drugs at an in-network specialist's office and a $20 copayment for provider 
and professional services at an in-network specialist's office.  
  You have been asked to pay a total of $236.40 for the arthrocentesis and Orthovisc injections.  
 
Date of Service Service Allowed Amount Cost Per Contract Member Liability 
May 12, 2022 Arthrocentesis $91.73 $20 $20 
May 12, 2022 Orthovisc Injection $309.50 19% $58.80 
May 19, 2022 Arthrocentesis $91.73 $20 $20 
May 19, 2022 Orthovisc Injection $309.50 19% $58.80 
May 26, 2022 Arthrocentesis $91.73 $20 $20 
May 26, 2022 Orthovisc Injection $309.50 19% $58.80 
TOTAL:    $236.40 
 
The arthrocentesis falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. The Orthovisc 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 cost for the arthrocentesis and Orthovisc injection provided from May 12, 
2022, through May 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 
22, 2022, through January 27, 2022. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you were told you would pay 
nothing due to COVID-19 and you need help paying this bill. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-5 and a $0 copayment per day for days 6-90 for each Medicare-covered hospital 
stay.  
  You have been asked to pay $1,625 for the inpatient stay ($325/day x 5 days = $1,625). The inpatient stay falls 
within the Inpatient Hospital Care 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 
the inpatient stay provided from January 22, 2022, through January 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. The enrollees care needs, as a practical matter, can be 
provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) from an out-of-network provider 
provided on February 4, 2022. 
 
You asked the Plan to pay for hearing aids. You say that you did not realize until the claim was denied that the 
hearing aids had to be purchased through a specific hearing provider. The Plan denied your request. The Plan 
says there is no coverage if ordered through providers other than the plan's hearing vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by the Plans hearing aid provider.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were provided by an out-of-
network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) from an out-
of-network provider provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT) for the 
enrollee. 
 
You asked the Plan to pre-approve this treatment. In both your appeal to the Plan and additional information 
submitted to the Plan dated September 7, 2022, you say that Stereotactic Body Radiation Therapy (SBRT) is 
medically necessary for this enrollee with a history or primary metastatic esophageal cancer and a recent 
diagnosis of limited stage small cell lung cancer.  
 
The Plan denied your request. The Plan says the required Medicare coverage criteria are not met. The Plan 
stated that the records show the enrollee has advanced stage IV esophageal adenocarcinoma and has gone 
through a cycle of FOLFOX and had radiation therapy to the esophageal tumor mass, including the 
innumerable lesions in his liver. The records show the enrollee had progression and went through a round of 
pembrolizumab. A nodule in his right lung received SBRT in March 2022. A positron emission tomography 
(PET) scan in June 2022 revealed two (2) new 5 cm masses. One in the right lung, which was biopsied and 
found to be separate cancer-type (small cell lung cancer), and the other in the liver which was determined to be 
a recurrence of the esophageal adenocarcinoma. The enrollee is currently undergoing chemotherapy and SBRT 
for the lung cancer. The request is now for SBRT for the recurrence of the esophageal adenocarcinoma in the 
liver. The Plan states that according to the Medicare Local Coverage Determination (LCD): L35076, SBRT is 
only indicated as primary treatment for tumor types or locations where the available published literature 
supports an outcome advantage over other conventional radiation modalities. The LCD states that SBRT is not 
considered medically necessary under the following circumstances for any condition: Treatment is unlikely to 
result in clinical cancer control and/or functional improvement. SBRT of the members solitary lesion is 
unlikely to result in clinical control of his widely spread cancer. The LCD further states treatment, of anybody 
site or internal organ, is indicated for treatment of recurrence in or near previously irradiated regions when a 
high level of precision and accuracy or a high dose per fraction is indicated to minimize the risk of injury to 
surrounding normal tissues and treatment with conventional methods is not appropriate or safe for the patient. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for SBRT. Based on the medical 
records and the LCD coverage requirements, the enrollees disease has not responded to this type of treatment 
previously. The required Medicare criteria for coverage of this treatment are not met. Therefore, we decided 
that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response provided on March 21, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that there is no other means of transportation in 
the area. The Plan denied your request. The Plan says there is no Medicare covered ambulance benefit if 
transport does not occur. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response provided on March 21, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator 
provided on July 8, 2021. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you do not 
agree with the coinsurance that was assessed. The Plan denied your request. The Plan says the coinsurance 
applied was 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 20% 
coinsurance for durable medical equipment and related supplies. The allowed amount of the claim is $2,931.45, 
resulting in a coinsurance amount of $586.29 ($2,931.45 x 20%). 
 
You have been asked to pay $586.29 for an automatic external defibrillator. An automatic external defibrillator 
falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an automatic external defibrillator provided on July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be administered at the current facility until more appropriate for a lower level of care. The patient 
does not require services at the LTACH that are not already available at the current facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.