Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for a fluorescein angiography and an office visit. We decided that the Plan 
does not have to pay for a treatment of retinal lesion.  
 
You asked the Plan to pay for a treatment of retinal lesion (67210), a fluorescein angiography (92235) and an 
office visit (99214) billed for date of service May 13, 2020. You say that the medically necessary services at 
issue were provided in good faith. The Plan says that rules for payment have not been met. 
 
We decided that the Plan has to pay for a fluorescein angiography and an office visit.  
 
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. Specifically, the Plan has indicated that the request for payment for a fluorescein 
angiography and an office visit constitutes a duplicate claim. The provided documentation of the prior claim 
does not support that a fluorescein angiography and an office visit have been previously paid. The Plan has not 
provided any clear alternative denial rationales. It is the Plans responsibility to substantiate its denial with 
evidence. In this case, the Plans denial has not been substantiated, so we must find in your favor. Therefore, 
we decided that the Plan has to pay for a fluorescein angiography and an office visit.  
 
We also decided that the Plan does not have to pay for a treatment of retinal lesion. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that a treatment of retinal lesion was 
reimbursed by the Plan on June 20, 2020. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that a treatment of retinal lesion was provided twice on the same 
date. Based on this information, we decided that the Medicare rules for a treatment of retinal lesion have not 
been met. Therefore, we decided that the Plan does not have to pay for a treatment of retinal lesion. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eye exam (S0620) and routine eyewear (V2781, 
V2020, V2784, V2744, V2750) provided on July 22, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the routine eye exam and routine eyewear. You say that you would like an 
exception because you cannot afford the cost of the services. The Plan denied your request. The Plan says these 
services are not covered because they were not provided by a network vision provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network optical provider. 
 
We looked at the file and the Plan's rules. The routine vision services at issue were not provided by a network 
optical provider. Based on this information, we decided that the Plan's rules for coverage of the routine eye 
exam and routine eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the 
routine eye exam (S0620) and routine eyewear (V2781, V2020, V2784, V2744, V2750) provided on July 22, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.   
 
We reviewed the case file and Medicare rules. Based on this information, we find that the enrollee does not 
meet Medicare criteria for coverage of the requested service. Specifically, the rules say that Medicare covers 
one annual LDCT scan for lung cancer screening for enrollees who are between 55 and 77 years of age. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening (71271).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on June 16, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that this should be covered and was medically necessary. The 
Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
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 lab work provided on June 16, 2022, by an out-of-
network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit and ecg 
 
You asked the Plan to waive the copayment for an emergency room visit and ecg. You say that you were never 
given an ecg or anything like that and want your copay back. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $90 
copayment for emergency care.  
 
You have been asked to pay the allowed amount of $74.82 which is less than the $90 copayment for an ER 
visit. This item/service falls within the emergency 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 an emergency room visit and ecg.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (G0481) provided on December 22, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services are not covered when provided OON. 
 
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 lab services (G0481) provided on December 
22, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), manual therapy techniques 
(97140), and the group therapeutic procedures (97150) rendered by the out-of-network (OON) provider on  
July 21, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the therapeutic exercises (97110), manual therapy techniques (97140), and the 
group therapeutic procedures (97150) rendered by the out-of-network (OON) provider on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on August 14, 
2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment for Urgently needed services.  
 
You have been asked to pay a $30 copayment for urgent care visit. This item/service falls within the Urgently 
needed 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 urgent care visit provided 
on August 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a methylprednisolone injection (J1030) 
provided on May 10, 2022. 
 
You asked the Plan to waive the coinsurance for the methylprednisolone injection. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says this cost 
sharing was charged 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 20% 
coinsurance for Medicare Part B Prescription Drugs.  
 
 
  You have been asked to pay a 20% coinsurance for the methylprednisolone injection ($1.19). This item/service 
falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a methylprednisolone injection (J1030) provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen system and the oxygen 
concentrator provided on April 16, 2022, May 16, 2022, June 16, 2022, July 16, 2022, and August 16, 2022. 
 
You asked the Plan to waive the coinsurance for the oxygen system and the oxygen concentrator. You say that 
you never used the equipment. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for Medicare-covered durable medical equipment. The total amount charged for each date of 
service was $127.66 with a coinsurance amount of $25.53 ($127.66 total amount x 20% coinsurance). The total 
amount for the coinsurance for all dates of service was $127.65 ($25.53 coinsurance each date of service x 5 
dates of service). 
 
  You have been asked to pay a $127.65 coinsurance for the oxygen system and the oxygen concentrator. This 
item/service 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 the oxygen system and the oxygen concentrator provided 
on April 16, 2022, May 16, 2022, June 16, 2022, July 16, 2022, and August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on June 01, 2022, to 
June 04, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment per admit for inpatient hospital stay. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. 
 
 
 
 
 The enrollee has been asked to pay a $325 copayment for inpatient hospital stay. This item/service falls within 
the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital stay on June 01, 2022, to June 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty in conjunction with extractions - four or more 
teeth or tooth spaces, per quadrant (D7310) provided on March 24, 2022. 
 
You asked the Plan to pay for the alveoloplasty in conjunction with extractions - four or more teeth or tooth 
spaces, per quadrant (D7310). You say that the dental facility told you that all of the codes were covered. The 
Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) 
provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary. The Plan 
denied your request. The Plan says you cannot safely operate a power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
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 power wheelchair. Our reviewer says 
that the requested a power wheelchair is not shown to be medically necessary.  Our physician reviewer found the medical records document unsafe use of the power wheelchair, which could 
be a danger to your health and safety. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on April 19, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plans network) will not be covered. 
 
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 outpatient mental health provided on April 19, 
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 a podiatrist visit in a skilled nursing facility (SNF) provided 
on July 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a podiatrist visit in a SNF. You say that the enrollee is in a facility and the 
facility should have obtained the prior authorization. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a podiatrist visit in a skilled nursing facility (SNF) 
provided on July 16, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric visit provided on June 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the psychiatric visit. You say that the service rendered is routine and previous 
claims were paid. The Plan denied your request. The Plan says the rendering provider is an OON provider and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a psychiatric visit provided on June 17, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor kit. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 Sensor kit. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 Sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Sensor kit.