Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 1, 2022, to March 7, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were billed for being in the 
ICU but you were not there. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $375 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The file shows that you were in the hospital from March 1, 2022, to March 7, 2022. Please note that the 
copayment is based on the level of care received, not the location. Therefore, you have been asked to pay $375 
per day for 5 days of inpatient care. The total for your stay is $1,875 ($375 copayment x 5 days = $1,875). The 
inpatient care falls within the Inpatient Hospital Care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided from March 1, 2022, to March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued 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 at the current level of function, you do not require daily skilled therapy 
services on an inpatient basis. 
 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 
SNF services are not medically reasonable and necessary. You do not have documented skilled nursing needs. 
You do not have documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. Your care needs can, as a practical 
matter, be provided at a lower level of care. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 12, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-rays (D0230) provided 
on December 30, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that the provider did not show 
up to the first appointment which you had x-rays taken at. You also say at the second appointment, more x-rays 
were taken, and you were still not treated by the doctor. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. 
 
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 the 
additional intraoral periapical x-rays (D0230) provided on December 30, 2021.  
 Your complaint about being charged for services that were rendered by a provider you never saw 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 laboratory testing provided on January 14, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because lab testing related 
to treatment of end-stage renal disease (ESRD) is bundled into dialysis services and is not separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD prospective payment system 
(PPS) and are not paid separately.  
 
We looked at the file and Medicare rules. This testing was related to ESRD; therefore, it is included in the 
ESRD PPS payment and is not paid separately. Based on this information, we decided that Medicare rules for 
coverage of lab testing have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory testing provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5257) provided on November 24, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you are not sure if you are out-of-network with the 
Plan because you have been part of the network for a while, and would like to continue being in-network. The 
Plan denied your request. The Plan says these hearing aids were rendered by an OON provider. The Plan also 
says that hearing aids are only covered if they are ordered through the Plan's hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the enrollee uses the Plan's hearing aid vendor to receive hearing aid benefits. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5257) provided on November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) and 
accessories provided on February 17, 2022. 
 
You asked the Plan to pay for the CPAP and accessories. You say that you would like this claim approved and 
covered. The Plan denied your request. The Plan says that this service was provided by a non-participating, 
non-Medicare certified provider. 
 
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who 
is not enrolled in the Medicare Program. 
 
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to pay for the continuous positive airway pressure (CPAP) and accessories provided 
on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on December 20, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you had to go where you could get the strongest 
hearing aids because you are 80 percent deaf in both ears. The Plan denied your request. The Plan says they 
confirmed with the treating facility that you did not provide any insurance information. The Plan also says that 
the treating facility is not in-network with the Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) provided on December 20, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
provided on April 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the TENS device. You say that the provider told you the device would be free, 
and you only had to pay the shipping. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers 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 transcutaneous electrical nerve stimulation 
(TENS) device provided on April 22, 2022, by an out-of-network (OON) provider.  Your complaint about your experience with this provider 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: Favorable

 
We decided that the Plan has to pay for the gene panel testing provided on December 10, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says that one code 
must be submitted for the panel. 
 
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. 
 
We find that the gene panel at issue was billed with CPT code 81479. The case file does not include any 
additional claims or claim information to show that additional codes were billed for the gene panel. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the gene panel testing provided on 
December 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wearable cardiac defibrillator, LifeVest (K0606). 
 You asked the Plan to pre-approve the LifeVest. You say that in order to rule out hypertrophic cardiomyopathy, 
the doctor ordered a cardiac MRI. He would like the enrollee to continue to wear the LifeVest until 
hypertrophic cardiomyopathy is ruled in or out. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for extension of LifeVest. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the LifeVest. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee had an echocardiogram 5/17/2022 showing an ejection fraction of 45-50%, 
while a cardiac MRI on 6/10/2022 described the left ventricle as mildly dilated with moderately reduced 
ejection fraction of 37%. The wearable defibrillator is a vest like device worn under the clothing that 
continuously monitors the heart rhythm and automatically delivers an electric shock when VF or VT is 
detected. This device is intended to be worn continuously, 24 hours per day, except when the wearer is bathing 
or showering. As such, it would not appear that the enrollee was a candidate for a wearable defibrillator 
according to current guidelines. In summary, authorization and coverage of the wearable defibrillator would 
not be considered 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 the LifeVest have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the wearable cardiac defibrillator, LifeVest (K0606).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45378) provided 
on April 20, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the colonoscopy was a 
preventative procedure, and no one advised it was diagnostic in nature or that a biopsy was done. The Plan 
denied your request. The Plan says the copayment was applied correctly. The Plan says the medical records 
indicate you needed a colonoscopy to identify the cause of abdominal pain in the lower right quadrant. Since 
the procedure was ordered in response to an existing issue, it is not considered a screening colonoscopy. 
 
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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $200 copayment for a diagnostic colonoscopy. Diagnostic colonoscopies fall 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy 
(45378) provided on April 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on September 17, 2021. 
 
You asked the Plan to pay for the physician 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 1, 2021. The services in question were provided 
before the end of that month. Additionally, the record shows that the enrollee re-enrolled in the hospice benefit 
on September 18, 2021. Therefore, we decided that the Plan does not have to pay for the office visit (99213) 
provided on September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
March 13, 2022, to March 16, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this inpatient stay was 
the hospital's fault, as you were only there due to surgical complications. 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 $325 
copayment per admission for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per admission for an inpatient stay. An inpatient hospital stay 
falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an inpatient hospital stay provided from March 13, 2022, to March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve right genicular radiofrequency ablation. You say that right genicular 
radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says right genicular 
radiofrequency ablation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 right genicular radiofrequency ablation. 
Our reviewer says that the requested right genicular radiofrequency ablation is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee has not had an adequate 
trial of physical therapy and has not had a surgical consultation. The request is considered not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right genicular radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve right genicular radiofrequency ablation.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that deviation from the plan will cause trouble with 
activities of daily living. The Plan denied your request. The Plan says the enrollee has not tried and failed one 
of the preferred agents. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox. Our physician reviewer found 
that the enrollee has cervical dystonia. The Plan requires a trial of Dysport and Xeomin before they will 
approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no 
documentation provided indicating that the Plans required drugs would likely be less effective or likely have 
adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.