Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the digital hearing aids (V5261) rendered by 
the out-of-network (OON) provider on February 1, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they was purchased from an out-of-network provider. 
 
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.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract states that hearing aids purchased 
outside of the Plans network are not covered. The hearing aids in this case were purchased from an  
out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for the 
digital hearing aids (V5261) rendered by the out-of-network (OON) provider on February 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on December 28, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for an ultrasound.  
 
You have been asked to pay a $100 copayment for an ultrasound. an ultrasound 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 an ultrasound on December 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 24, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not have a $50 
copayment for an ultrasound, when you had already paid a copayment to see the provider. 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 $50 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $50 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies, not Including X-Rays 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 ultrasound provided on February 24, 2022.  
 Your complaint about the plan not being transparent enough is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 21, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that the provider didn't tell you they were out-of-
network. 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 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 laboratory services provided on January 21, 
2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 29, 2021. 
 
  You asked the Plan to pay for physical therapy services. You say that plans are required to pay non-contract 
providers at the preferred provider rate when services are not available from preferred providers in the service 
area. You say that in-network benefits should be honored, and the claim processed for payment. The Plan 
denied your request. The Plan says a claim for CPT code 97110 billed by this provider was already paid on 
November 5, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be an exact duplicate are rejected and do not have appeal rights.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have been met. Specifically, the physical therapy services were already 
paid on another claim. Therefore, we decided that the Plan does not have to pay for this claim of physical 
therapy services provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81272, 81275, 81276, 
81292, 81295, 81298, 81301, 81311, 81317, 81321, 81194) provided February 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 lab services (81206, 81210, 81235, 81272, 81275, 
81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321, 81194) provided February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on March 8, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on March 8, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic provided on January 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychiatric diagnostic. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 psychiatric diagnostic provided on January 11, 
2022, by an out-of-network (OON) provider.
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 member is receiving appropriate in-patient acute care and 
is currently unstable for transfer to an LTACH. 
 
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 enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90832) provided 
December 14, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the records do not show that the mental health provider 
attempted to consult the enrollee's primary physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for outpatient mental health 
services (90832) provided December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left atrial appendage closure (LAAC) device and 
inpatient hospital admission. 
 You asked the Plan to pre-approve a LAAC device and inpatient hospital admission. 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 follows Medicare rules. Medicare rules say that LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that devices FDA-approved 
indication and meet specific conditions. 
 
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 LAAC device and inpatient hospital 
admission. Our reviewer says that the services are not medically necessary. Our physician reviewer found there 
is no contraindication to anticoagulation according to the physician. As such, guidelines would not support 
implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or 
medically necessary in this enrollees clinical management. 
 
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 LAAC device and inpatient hospital admission have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a left atrial appendage closure (LAAC) device and 
inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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. 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic breast tomosynthesis (77062) provided on 
September 1, 2021. 
 
You asked the Plan to pay for a diagnostic breast tomosynthesis. You say that the service at issue was billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of a diagnostic breast tomosynthesis have not been met. Therefore, we decided that the Plan does not 
have to pay for a diagnostic breast tomosynthesis (77062) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on January 10, 2022. 
 
You asked the Plan to pay for the eye exam. The Plan denied your request. The Plan says a routine eye exam is 
offered from a Plan vision provider. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision 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 the Plans vision provider. 
 
We looked at the file and the Plan's rules. The file shows that the eye exam was not provided by the Plans 
vision provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam have 
not been met. Therefore, we decided that the Plan does not have to pay for an eye exam provided on  
January 10, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for Emergency Room Services (ER) on June 25, 2021. 
 
You asked the Plan to waive the copayment for Emergency Room Services (ER). You say that you thought it 
was at urgent care and believe it should only a $30.00 copay. The Plan denied your request. The Plan says that 
the cost-sharing you are being charged is correct. 
 
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. Without the correct Evidence of Coverage (EOC), there is no way of knowing 
whether the copayment being charged is correct. Therefore, we decided that the Plan has to waive the 
copayment for Emergency Room Services (ER) on June 25, 2021.  
 
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 waive the copayments and pay for the chiropractic services rendered 
on January 11, 2022, and January 13, 2022. 
 
You asked the Plan to waive the copayments and pay for these services. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were 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 a $20 
copayment for in-network Medicare-covered chiropractic services.  Review of the file shows that you received chiropractic manipulation on January 11, 2022, and January 13, 
2022. You have been asked to pay a $20 copayment per date of service for these services, for a total of $40. 
These services fall within the in-network Medicare-covered chiropractic 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.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
The file shows that the provider billed procedure code 99202 (office visit). This code is not covered when 
billed by a chiropractor. 
 
Therefore, we decided that the Plan does not have to waive the copayments and pay for the chiropractic 
services rendered on January 11, 2022, and January 13, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for medication assisted treatment provided from September 17, 2021, to 
December 31, 2021. We decided that the Plan does not have to pay for medication assisted treatment provided 
from January 7, 2022, to April 2, 2022.   
 
You asked the Plan to pay for medication assisted treatment provided from September 17, 2021, to April 2, 
2022. You say that you are appealing with supporting records. The Plan says that the rendering provider is not 
eligible to perform the services billed. 
 
We decided that the Plan has to pay for medication assisted treatment provided from September 17, 
2021, to December 31, 2021.   
 
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 failed to provide the requested 2021 Evidence of Coverage (EOC) for 
this appeal. Without the correct 2021 EOC, we cannot determine whether the non-participating provider is able 
to be paid for the submitted claims. Therefore, we decided that the Plan has to pay for medication assisted 
treatment provided from September 17, 2021, to December 31, 2021.   
 
We also decided that the Plan does not have to pay for medication assisted treatment provided from 
January 7, 2022, to April 2, 2022. 
 
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 medication assisted treatment provided from 
September 17, 2021, to December 31, 2021.  
 
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.