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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on June 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. 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). Your contract with the Plan clearly says that you must pay a $300 
copayment for outpatient surgery services. Covered services include, but are not limited to services in an 
emergency department or outpatient clinic, such as observation services or outpatient surgery. 
 
You have been asked to pay a $300 copayment for outpatient surgery. This item/service 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 outpatient 
surgery on June 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says it is not an accepted treatment to give this drug for your type of cancer, and there 
are other proven treatments that might help you. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the requested use of Keytruda DA-approved for your diagnosis. The use is not supported by one of the 
major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 
(CMS)-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (CPT code J9271).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for outpatient therapy services provided from June 15, 2022, to June 17, 
2022.  
 
You asked the Plan to pay for therapy services. The Plan denied your request.  
 
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 did not provide the complete case file for us to review. Without the 
case file we are unable to determine if the Plan was correct in their decision to deny your request. Therefore, 
we decided that the Plan has to pay for outpatient therapy services provided from June 15, 2022, to June 17, 
2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and coronavirus test (87635) 
provided on May 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you were not aware that the services were 
not paid. The Plan denied your request. The Plan says there are in-network urgent care facilities in the area. 
 
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 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 office visit (99203) and coronavirus test (87635) provided on May 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 76775. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76775 is bundled into payment for code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76775 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76775 billed for date of service May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need inserts to heal a medical issue with 
your foot. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) and consultation (99244) 
provided on January 22, 2022 to January 23, 2022. 
 
You asked the Plan to pay for the electrocardiogram and consultation. You say that the services were medically 
necessary and should be covered. The Plan denied your request. The Plan says the codes billed are not 
supported by the documentation. The provider must submit corrected claims. 
 
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 CPT code 93010 & 99244 is not supported in the medical record. Specifically, code 93010 is 
included in code 93458 which was also billed. This is a bundled service and not separately payable. Code 
99244 has a status indicator of I per the Physician Fee Schedule and is not eligible for Medicare payment. 
Based on this information, we decided that Medicare rules for coverage of the electrocardiogram and 
consultation have not been met. Therefore, we decided that the Plan does not have to pay for an 
electrocardiogram (93010) and consultation (99244) provided on January 22, 2022 to January 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable contact lenses (S0500) purchased on April 11, 
2022, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the disposable contact lenses. You say that your reimbursement request should 
be honored because the provider was in-network when the prescription was written, and the prescription is still 
valid. The Plan denied your request. The Plan says you purchased these contact lenses from an OON provider. 
The Plan also says that services from OON providers are not covered. 
 
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 they are obtained from a provider in the Plans vision vendor 
network. 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you purchased these contact 
lenses from an OON provider. The contract clearly states that services obtained from vendors outside the Plan's 
network are not covered. Based on this information, we decided that the Plan's rules for coverage of the 
disposable contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the 
disposable contact lenses (S0500) purchased on April 11, 2022, from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye medical examination and evaluation 
(92012) provided on May 20, 2022. 
 
You asked the Plan to waive the copayment for an eye medical examination and evaluation (92012). You say 
that you did not request the vision service. You also say there was no eye examination given. 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 
copayment for each Medicare-covered eye examination to treat an eye condition.  
 
 
  You have been asked to pay a $20 copayment for an eye medical examination and evaluation (92012). This 
item/service falls within the Medicare-covered eye examination to treat an eye condition 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 eye medical examination and evaluation (92012) 
provided on May 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy, 30 minutes, (90832) provided on July 9, 
2021. 
 
You asked the Plan to pay for the psychotherapy service. You say that the service should be covered. 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 psychotherapy, 30 minutes, (90832) provided on July 9, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you are disabled and need to have this 
authorization approved. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on December 6, 2021, by an OON 
provider. 
 
You asked the Plan to pay for a drug test. You say that you are appealing the claim payment denial for services 
rendered to the enrollee. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
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 drug test provided on December 6, 2021, by an 
OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on December 28, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and contacted the ambulance to help you up. You also say that you did not want to be transported to the 
hospital. The Plan denied your request. The Plan says the ambulance was called but you were not transported to 
an emergency facility. 
 
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 December 28, 2021. 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 and treatment with no 
transport (A0998) provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 14, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating the 
member has a policy and address per the Plan's policy and the office visit should be covered. The Plan denied 
your request. The Plan says the out-of-network services were not authorized. 
 
 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 an office visit provided on July 14, 2022, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested supplies are a 
medical necessity for you. The Plan denied your request. The Plan says that rules for coverage for CGMs and 
related supplies have not been met. 
 
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 denied coverage for a CGM, stating that you do not 
meet the coverage criteria because you are not being treated with insulin. The Plan has not provided medical 
records or other documentation to support that you are not being treated with insulin. It is the Plan's 
responsibility to substantiate its denial with evidence. In this case, the denial has not been substantiated, so we 
must find in your favor. Therefore, we decided that the Plan has to pre-approve a CGM and related supplies.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services (92012) provided on June 10, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not obtained. 
 
  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 ophthalmological services (92012) provided on 
June 10, 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 shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you had surgery and need to have this item 
urgently, this for safety reasons. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Uptravi tablets. 
 
You asked the Plan to pre-approve Uptravi. You say that Uptravi is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B 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 Uptravi tablets.  
 
Benefits for Uptravi may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for chemotherapy. We decided that the Plan does not 
have to waive the coinsurance for infusions.  
 
You asked the Plan to waive the coinsurance for chemotherapy and infusions provided on March 10, 2022. You 
say that you had already paid a $200 copayment for these services and were not made aware of these additional 
charges. The allowed amount of this item or service was $10,885.96, resulting in a coinsurance of $1,844.51 
($10,885.96 x 20% = $1,844.51). The Plan says that this cost sharing was charged correctly. 
 
 We decided that the Plan has to waive the coinsurance for chemotherapy.  
 
The Plan follows Medicare rules. Medicare rules say that there is a 20% coinsurance ($96.04) on Medicare Part 
B prescription drugs.  
 
The file shows that you have a medical indication for which Medicare will cover chemotherapy. Therefore, we 
decided that the Plan has to waive the coinsurance for chemotherapy.  
 
We also decided that the Plan does not have to waive the coinsurance for infusions. 
 
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 infusions. Therefore, we decided that the Plan does not have to waive the coinsurance for 
infusions. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee is developmentally 
disabled, and wears incontinence supplies every night. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.