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

 
We decided that the Plan does not have to pay for x-rays of the femur provided on April 19, 2023. 
 
You asked the Plan to pay for x-rays of the femur. You say that this is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for x-rays of the femur 
provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on March 17, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit for 
evaluation provided on March 17, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
April 08, 2023. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you say that the plan 
should covered this copayment. 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 $90 
copayment for outpatient hospital services. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency 
room services provided on April 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on March 13, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit for 
evaluation provided on March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81240, 81241). 
 
You asked the Plan to pre-approve genetic testing. You say that you need to know if the enrollee has the 
clotting factor and if she will have any complications during or post procedure. The Plan denied your request. 
The Plan says the F2 and F5 genetic tests are not considered to be clinically efficacious; therefore, testing 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clinical need for genetic testing prior to a routine total hip replacement (THR) 
surgery for this 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81240, 81241).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
December 12, 2022, to December 21, 2022. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that the provider who did 
this surgery should pay the copayment, as you were hospitalized due to complications from his procedure. 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 $360 
copayment per day, for days 1 to 5 for inpatient hospital services.  
 
You were in the hospital for 5 days, resulting in a $1800 total copayment ($360 x 6 = $1800). You have been asked to pay a $1800 total copayment for an in-network inpatient stay. This item/service falls 
within the inpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network inpatient stay provided from December 12, 2022, to December 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 10, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 home health services have been 
met. No OASIS documentation was submitted. Insufficient records were provided to support the billed service.  
Therefore, we decided that the Plan does not have to pay for home health services provided on March 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone provided on April 5, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone. You say that you have been a 
Substance Abuse and Mental Health Services Administration (SAMHSA) certified provider since 2004. The 
Plan denied your request. The Plan says that the charge for the drug and its administration must be billed by the 
Medicare-enrolled Opioid Treatment Program. 
 
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 rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for medication assisted 
treatment, methadone provided on April 5, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to lower the coinsurance for in-network imaging with diagnostic 
Technetium provided on March 7, 2023. 
 
You asked the Plan to lower the coinsurance for in-network imaging with diagnostic Technetium . You say that 
this should be a lower coinsurance amount, not 20%. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered medical supply.  
 
The allowed amount of this drug is $901.16, resulting in a coinsurance amount of $180.23 ($901.16 x 20% = 
$180.23). You have been asked to pay a $180.23 coinsurance for in-network imaging with diagnostic Technetium. This 
item/service falls within the for each Medicare-covered medical supply 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 lower the coinsurance for in-network imaging with diagnostic Technetium provided on March 
7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. There 
is no documentation provided to support the expectation you will require a greater than two midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found the record indicates that you are scheduled for elective total right hip 
arthroplasty. The record provided does not indicate that the treating physician has a reasonable expectation of a 
length of stay spanning two or more midnights, taking into account complex medical factors. The initial day 
may be spent in observation until it is clearly expected that a second midnight would be required, at which time 
the physician may order inpatient admission. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance (E0486) to be provided by an out-of-
network (OON) provider at the in-network level of benefit. 
 
You asked the Plan to pre-approve an oral appliance. You say that you would like the requested provider to be 
covered as in network under your 20% coinsurance benefit. The Plan denied your request. The Plan says your 
plan does have out of network benefits and there is one participating provider to provide this service. 
 
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 
an oral appliance (E0486) to be provided by an out-of-network (OON) provider at the in-network level of 
benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network oxygen equipment provided 
from January 15, 2023, to March 15, 2023. 
 
You asked the Plan to waive the coinsurance for in-network oxygen equipment. You say that you should not be 
getting charged the 20% for this item, you had an agreement to pay $12 per month. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
The allowed amount of this item was $163.26 resulting in a coinsurance of $32.65 ($163.26 x 20% =$32.65). 
You had this item for 3 months, resulting in the $97.95 total coinsurance ($32.65 x 3 months = $97.95). You have been asked to pay a $97.95 total coinsurance for in-network oxygen equipment. This item/service 
falls within the durable medical equipment (DME) and related 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 coinsurance for in-network oxygen equipment provided from January 15, 2023, to 
March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on March 21, 2023. 
 
You asked the Plan to pay for an eye exam. You say that this should be covered at no cost to you as it is a 
routine eye exam. Please cover. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an eye exam provided 
on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hematology/oncology services to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the hematology/oncology services. You say that you are requesting 
reconsideration of the denied service. The Plan denied your request. The Plan says this service was not 
approved. 
 
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 hematology/oncology services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97813 x 6) 
rendered by the out-of-network (OON) provider from January 4, 2023, through January 25, 2023.  
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
they were rendered by an out-of-network provider.  
 
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 issue reimbursement for  care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.   
 
 
 
 
 
We found no exception that would require the Plan to issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97813 x 6) rendered 
by the out-of-network (OON) provider from January 4, 2023, through January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that it is medically necessary for you to know what your 
blood sugar level is. The Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not collect medical records from their participating 
provider who ordered the requested CGM. Participating providers are considered agents of the Plan. Without 
this necessary documentation we are unable to make a determination as to whether the enrollee has met the 
criteria for coverage of a CGM. Phone call logs regarding particulars of an enrollee's condition is not an 
acceptable substitution for medical records. Therefore, we decided that the Plan has to pre-approve a 
continuous glucose monitor (CGM).  
 
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 a Life2000 home mechanical ventilator. 
 
You asked the Plan to pre-approve a Life2000 home mechanical ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Life2000 home mechanical ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. You could be treated with a bilevel positive airway pressure (BiPAP) machine with  
average volume assured pressure support (AVAPS) capability and failure of such a device has not been 
documented. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
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 Life2000 home mechanical ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Life2000 home mechanical ventilator.