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

 
We decided that the Plan does not have to pre-approve the ophthalmology office visit to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology office visit. You say that you have been seeing this eye 
doctor for many years at this specific office location. You say you were disappointed with your Plan-assigned 
doctor. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the ophthalmology office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to lower the copayment for a medical eye examination (92014). We also decided 
that the Plan does not have to waive the copayment for fundus photography (92250) and a medical eye 
examination (92014). 
  You asked the Plan to waive the copayment for a medical eye examination (92014) and fundus photography 
(92250) provided on June 10, 2022. You say that it was a routine eye examination. The Plan says that you pay 
a $50 copayment for a medical eye examination (92014) for services from an in-network provider. The Plan 
also says you pay a $25 copayment for fundus photography (92250) for services from an in-network provider. 
 
We decided that the Plan has to lower the copayment for a medical eye examination (92014).  
 
The Plan follows Medicare rules. Medicare rules say that a health 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 $45 copayment for Medicare-covered vision care benefits 
including diagnoses and treatment for diseases and conditions of the eye (including diabetic retinopathy). 
 
The file shows that you have a medical indication for which Medicare will cover a medical eye examination. 
The Plan contract also says there is a $45 copayment for Medicare-covered vision care benefits including 
diagnoses and treatment for diseases and conditions of the eye (including diabetic retinopathy). The record 
shows that the eye examination was medical and not for routine services. The Plan actually should have 
charged a $45 copayment for this service.  
 
We also decided that the Plan does not have to waive the copayment for fundus photography (92250) and 
a medical eye examination (92014). 
 
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 $25 copayment for other Medicare-covered outpatient diagnostic procedures and tests. Your contract with the 
Plan also clearly says that there is a $45 copayment for Medicare-covered vision care benefits including 
diagnoses and treatment for diseases and conditions of the eye (including diabetic retinopathy). Therefore, we 
decided that the Plan does not have to waive the copayment for fundus photography (92250) and a medical eye 
examination (92014). 
 
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 pay for the durable medical equipment provided on August 11, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that you still have appointments 
with various doctors, and that you will need transportation. The Plan denied your request. The Plan says the 
benefit has exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation trips.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for endoscopy on June 21, 2022. 
 
You asked the Plan to waive the copayment for endoscopy. 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 $250 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.  If you are having surgery in a hospital facility, you should check with your provider about whether you 
will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the 
hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the 
hospital overnight, you might still be considered an outpatient. The provider billed in the amount of $2,131 
and the allowed amount is $197.22. This is less than the copayment amount. Therefore, resutls in the total cost 
sharing amount of $197.22. You have been asked to pay a $197.22 copayment, which is less than the copayment for endoscopy. This 
item/service falls 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 endoscopy 
on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 4, 2022 to June 28, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that these services should be covered because 
chiropractic services are covered. The Plan denied your request. The Plan says there is no referral on file from 
your primary care provider for the services rendered. 
 
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 chiropractic services provided on May 4, 2022 to 
June 28, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services provided on March 4, 2022 to July 
7, 2022. 
 
You asked the Plan to pay for the home health aide services. You say that you expect the balance of $2,592 to 
be provided. You also say that per the Evidence of Coverage home health agency care is covered. The Plan 
denied your request. The Plan says the services obtained were provided by a provider who is not under contract 
with the Plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for home health aide services provided on 
March 4, 2022 to July 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 29, 2022, to 
June 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this was medically necessary. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 29, 2022, to June 
27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70554 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 70554. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70554 is bundled into payment for 
code 70551. 
 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 70554 is a column II code to column I code 70551. 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 70554 
billed for date of service July 5, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code A9270 billed from June 27, 2022, to June 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that you were told the bill would be paid. The Plan 
denied your request. The Plan says that the service is non-covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The services at issue were rendered by a contract provider. The file does not show that the Plan provided notice 
that the billed services would not be covered. Under Medicare rules, this means the billed services are 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for procedure code A9270 
billed from June 27, 2022, to June 30, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexlansoprazole capsule 60mg DR. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have pharmacy/drug benefits administered by the plan. 
 
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 Dexlansoprazole capsule 
60mg DR.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 7, 2022, to April 13, 2022. 
 
You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled need. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the health plan has authorized care at the skilled level from March 23, 2022, to 
April 6, 2022. The issue is the medical necessity for continued care in a skilled nursing facility from April 6, 
2022, to April 13, 2022. The enrollee was residing in the skilled nursing facility at a custodial level of care 
when there was a change in condition that required admission into an acute hospital. The enrollee was treated 
with skilled care at the time he was readmitted into the SNF. The enrollee continued to decline and was 
admitted to hospice from 4/7/22 through 4/13/22. The enrollee did not require skilled care from 4/7/22 through 
4/13/22.  The enrollee received skilled care from 3/23/22 through 4/6/22 but did not require skilled care from 
4/7/22 through 4/13/22. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from April 7, 2022, to April 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have pharmacy/drug benefits administered by the plan.
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 Dexlansoprazole capsule 60mg DR.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires continued hospital 
care to assist with their disease process and to allow them the time needed to recover to the point of self-care. 
The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee 
can safely receive the care they need in current hospital setting. 
 
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 enrollee is still unstable and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until they are more stable and ready for a lower level 
of care. 
 
   
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Kinova assistive robotic arm and related accessories. 
 
You asked the Plan to pre-approve the Kinova assistive robotic arm and related accessories. You say that this is 
medically necessary for your condition. The Plan denied your request. The Plan says the requested equipment 
is considered experimental/investigational. 
 
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 Kinova assistive robotic arm and 
related accessories. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the requested robotic arm is not 
known to be the standard of care for this patient's condition of spinal muscular atrophy or weakness from 
cervical radiculopathy/pathology or in widespread use for your condition based on scientific evidence. 
Additionally, the documentation does not reveal a recent detailed in person objective musculoskeletal and 
neuromuscular examination of the upper extremities that supports a need for the requested item. 
 
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 Kinova assistive robotic arm and related accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Kinova assistive robotic arm and related 
accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (22+ classes) provided to the enrollee on February 25, 2022.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the services have been met. An order
for 22 or more drug classes was not provided in this case. Therefore, we decided that the Plan does not have to pay for drug testing (22+ classes) provided to the enrollee on February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 
respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87633) provided on September 
29, 2021. 
 
You asked the Plan to pay for detection test by nucleic acid for multiple types of respiratory virus, multiple 
types or subtypes, 12-25 targets. You say that this testing was medically necessary. Plan denied your request. 
The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. In this case the requested testing is for greater than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of detection test by nucleic 
acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets have not been met. 
Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87633) 
provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 22, 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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 22, 2022.