Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to change the copayment for an ultrasound provided on October 12,
2021.
You asked the Plan to change the copayment for an ultrasound. You say that the copayment is wrong for the
service that was provided. The Plan denied your request. The Plan says the provider billed for the service and
the proper copayment was applied.
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 $175
copayment for Medicare-covered radiological diagnostic services.
You have been asked to pay a $175 copayment for an ultrasound. An ultrasound falls within 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 change
the copayment for an ultrasound provided on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectometry (83789) and drug testing services 
(80307 and G0480) provided on July 9, 2021. 
 
You asked the Plan to pay for the mass spectometry and drug testing services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not 
billed with the appropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mass spectometry and drug testing services have not been met. Specifically, this claim was billed with the office place of service code while the records suggest that the member's face-to-face service was 
rendered in an outpatient hospital facility. Therefore, we decided that the Plan does not have to pay for the 
mass spectometry (83789) and drug testing services (80307 and G0480) provided on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) provided on July 7, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that it was difficult to find an in-network provider for this 
exam. The Plan denied your request. The Plan says out-of-network services are only covered in certain limited 
circumstances. There were in-network providers who were accepting patients and could have performed these 
services. In addition, the Plan's call log indicates that you were provided information for in-network providers 
before the date in question. 
 
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 eye exam (92004) provided on July 7, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 1, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trazimera. 
 
You asked the Plan to pre-approve Trazimera. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not supported for the enrollee's condition. 
 
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 Trazimera. Our reviewer says that the 
requested use of Trazimera is not supported. Our physician reviewer found the record indicates that the enrollee 
has a history of two breast cancers, one HER2 positive, the other HER2 negative and now has a diagnosis of 
metastatic breast cancer, HER2 negative. The record indicates that the enrollee is being treated with Herceptin 
and Letrazole.  The record does not include an assessment of left ventricular function. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trazimera have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Trazimera.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for two (2) medical eye exams (92012, 92014) and ophthalmic diagnostic 
imaging (92134) provided on February 26, 20202, to March 23, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for vision services. You say that you disagree with the Plan's request for 
overpayment in this matter as you were advised by the Plan at the time of services were rendered that the 
patient had active coverage with your Plan and the Plan has waited well over one year to make this request 
leaving you no option to refile the claim with any other carrier. The Plan denied your request. The Plan says 
that the benefit payment should have been made after the other carrier(s). The Plan also says they must 
consider the payment made by the other carrier(s) to determine their correct benefit amount. 
 
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 stated that the member has another primary insurance 
carrier. The Plan has not forwarded any evidence to support this claim. It is the burden of the Health Plan to 
substantiate their 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 pay for two (2) medical eye exams (92012, 92014) and 
ophthalmic diagnostic imaging (92134) provided on February 26, 20202, to March 23, 2020 by an out-of-
network (OON) provider.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment charged for ambulance services provided 
on November 4, 2021. 
 
You asked the Plan to waive these services. You say that you cannot afford this copayment. The Plan denied 
your request. The Plan says this copayment is a contractual obligation. 
 
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 $250 for 
each ambulance trip. 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 $250 copayment charged for ambulance 
services provided on November 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on July 12, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because 
these services were medically necessary. The Plan denied your request. The Plan says there is no referring 
provider on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical 
Psychologist, if the patient consents, you must attempt to consult their attending or primary care physician 
about the provided services and document the consent or declination date to consultations and date of the 
consultations in the patients medical record. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, there is not a referring provider on this 
claim. Additionally, the records submitted do not indicate that the provider consulted the member's attending 
physician or primary care physician bout the services rendered. Therefore, we decided that the Plan does not 
have to pay for the psychotherapy services (90832) provided on July 12, 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.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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. Our physician reviewer found that the patient is a 75-year-old male who was admitted to the acute care hospital with subdural hematoma, encephalopathy, and acute respiratory failure requiring cranioplasty, mechanical ventilation, and wound care. Trach was placed. The course was complicated by leukocytosis requiring empiric antibiotics. Recent notes describe the leukocytosis as resolving on antibiotics and the patient is tolerating the T-piece. The patient appears to be improving and more stable and should only require short-term additional acute care services that can be safely administered at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at this time. Transfer to a lower level of care may be considered when treatment has completed. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2744, V2781, V2784) purchased on
November 17, 2021.
You asked the Plan to pay for the eyeglasses. You say that you have been to this provider in the past, and you
were concerned about the cost of the eyewear from in-network providers. The Plan denied your request. The
Plan says the provider in this case is not part of the Plan's routine vision vendor network. Services must be
received in-network in order to be eligible for coverage or payment. The Plan also verified that you were
provided information for in-network providers prior to the date in question.
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 up to $250 when they are received from a provider in the Plan's
specified routine vision vendor network.
We looked at the file and the Plan's rules. The provider in this case does not participate in the Plan's routine
vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses
(V2020, V2744, V2781, V2784) purchased on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services for eyeglasses provided June 23, 2021. 
 You asked the Plan to pay for the eyeglass remake. You say that you were dissatisfied with your lenses and had 
them remade and feel they should be covered. The Plan denied your request. The Plan says you are not eligible 
for a refund for the remake. 
 
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.  
 
We looked at the file and the Plan's rules. Though the Plan offers vision benefits in excess of Medicare 
coverage, remakes for eyeglasses are not covered under your Plans vision benefit.  Therefore, we decided that 
the Plan does not have to pay for the vision services for eyeglasses provided June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states your 
records also show that you do not need an intensive team (rehabilitation doctor and nurse, social worker, and 
therapists) to oversee your care. The Plan states you can safely receive the services you need in other settings, 
for example: a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 the review has determined that the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second annual wellness visit provided on June 15, 2021. 
 
You asked the Plan to pay for this service. You say that the Plan should pay for this visit. The Plan denied your 
request. The Plan says this benefit was exhausted and is only covered once a year.  
 
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 an annual wellness 
visit is covered once a year. Therefore, we decided that the Plan does not have to pay for a second annual 
wellness visit provided on June 15, 2021.
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 does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you receive oral medications. You have stable 
vital signs, and your lungs are clear. You were at a moderate to maximal assist level with bed mobility and 
transfers and remained non-ambulatory. You do not require skilled nursing or therapy services on a daily basis. 
You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 
facility setting. 
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have no daily skilled nurse or therapist needs.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 3, 2020, to September 8, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the DRG was updated. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 872 (septicemia or severe sepsis without MV 
>96 hours without MCC). 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 pay for the services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found vital signs were notable for fever and hypertension. The enrollee was not ill-appearing, toxic-
appearing, or diaphoretic. Mild diffuse abdominal tenderness was documented. Laboratory results were notable 
for mild leukocytosis. A scan of the abdomen demonstrated sigmoid inflammation and wall thickening. DRG 
392 esophagitis, gastroenteritis, and miscellaneous digestive disorders without MCC) was more appropriate in 
this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from September 3, 2020, to September 8, 2020.