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

 
We decided that the Plan does not have to pay for an office visit (99213) and laser surgery (17110, 17000, 
17003) provided on December 15, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an office visit and laser surgery with an out-of-network provider. You say that 
these services have been covered in the past with a copayment. The Plan denied your request. The Plan says 
this provider is not a network provider. These services were not urgent or emergent, nor were they approved in 
advance. 
 
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 an office visit (99213) and laser surgery (17110, 
17000, 17003) provided on December 15, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two extra batteries for a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve two extra batteries for a portable oxygen concentrator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for brief emotional/behavioral assessment provided on January 
12, 2023. 
 
You asked the Plan to pay for brief emotional/behavioral assessment. You say that the services were medically 
necessary. 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 brief 
emotional/behavioral assessment provided on January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81514 billed for January 12, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 81514 is not supported. 
 
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, the CPT Code Manual definition of code 81514 is infectious disease, bacterial vaginosis and 
vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, 
Megasphaera type 1, Bacterial Vaginosis Associated Bacteria-2 (BVAB-2), and Lactobacillus species (L. crispatus and L. jensenii), utilizing vaginal-fluid specimens, algorithm reported as a positive or negative for 
high likelihood of bacterial vaginosis, includes separate detection of Trichomonas vaginalis and/or Candida 
species (C. albicans, C. tropicalis, C. parapsilosis, C. dubliniensis), Candida glabrata, Candida krusei, when 
reported. 
 
We find that CPT code 81514 is not supported in the medical record. Specifically, the records show that there 
is a more appropriate code for the rendered services. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 81514 billed for January 12, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve additional physical therapy (PT) visits (beyond the 12 which were 
approved and received).  
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee was benefitting from PT and 
should be allowed to receive more.  The Plan denied your request. The Plan says that there were no records 
submitted showing response to therapy, which were not requested from the provider prior to denial of the 
appeal.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that the continuation of PT services is shown to be medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was seen with a history of stroke, falls, and dementia, and received 12 
approved PT sessions. He progressed from requiring maximal assistance for transfers to ambulation with 
minimal assistance. The enrollee showed a good response to therapy, and as the record shows, continued to 
progress to a contact guard assistance level of mobility with additional sessions. The denial of ongoing care 
was not appropriate.  
 
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 therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve additional physical therapy (PT) visits (beyond the 12 which were approved and received).   
 
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 pay more for the golimumab injection provided on February 16, 
2023. 
 
You asked the Plan to pay more for the golimumab injection. You say that you would like your claim 
reprocessed because you are being balance billed. 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 20% 
coinsurance for in-network Medicare Part B drugs, including chemotherapy drugs. 
 
  You have been asked to pay $104.80, which is less than 20% of the allowed amount for the golimumab 
injection. The allowed amount is $704 (20% x $704 = $140.80) but you have only been asked to pay $104.80. 
You should not be responsible for the balance bill of the claim. If the in-network provider is billing you for any 
amounts beyond the applicable cost-sharing, then you should contact the Plan. Golimumab injections fall 
within the Medicare Part B prescription drugs  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 pay more for 
the golimumab injection provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses and anti-reflective coating provided on 
August 8, 2022. 
 
You asked the Plan to pay for the progressive lenses and anti-reflective coating. You say that you should be 
reimbursed for what the Plan would allow for basic lenses after surgery. The Plan denied your request. The 
Plan says the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers standard frames and lenses. 
 
We looked at the file and the Plan's rules. Specifically, the services are considered enhancements and therefore, 
not covered. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses 
and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for the 
progressive lenses and anti-reflective coating provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 office visit provided 
on March 07, 2023.
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 admission to an IRF is medically necessary for the 
enrollee. The enrollee requires active and ongoing therapeutic intervention of more than two therapy disciplines 
(physical therapy and occupational therapy). The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an IRF. The services you need can be provided safely in other 
settings, for example, a skilled nursing facility (SNF), home with home health services or home with outpatient 
therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided December 5, 2022, to January 3, 2023. 
 
You asked the Plan to pay for home health services. You say that these services should be covered. The Plan 
denied your request. The Plan says that the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 5, 2022. The NOA was t received by the Plan on December 7, 
2022. Therefore, we decided that the Plan has to pay for home health services provided December 5, 2022, to 
January 3, 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: 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 admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. Skilled therapies at home or at a skilled nursing facility may be approved upon request. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 02, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. 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 office visit provided 
on February 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each debridement procedure provided on 
March 22, 2022, to March 28, 2022. 
 
You asked the Plan to waive the copayment for each debridement procedure. You say that you thought this 
service would be covered under the specialist 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 $295 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $295 copayment for each debridement procedure. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facilities 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 total amount you owe 
is $590 ($295 copayment x 2 procedures = $590). Therefore, we decided that the Plan does not have to waive 
the copayment for each debridement procedure provided on March 22, 2022, to March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous allograft injection into the lumbar disc 
region.  
 
You asked the Plan to pre-approve a percutaneous injection. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the requested procedure 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 a percutaneous injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this is a purely experimental treatment for back pain. More research is needed. 
 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 percutaneous injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous allograft injection into the lumbar disc region.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 28, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. 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 laboratory services 
provided on February 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit, and the nasal endoscopy 
provided on February 16, 2023. 
 
You asked the Plan to waive the copayment for the office visit and the nasal endoscopy. You say that you did 
not know that there would be an additional charge for the 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 a $50 
copayment for Medicare-covered outpatient diagnostic tests, and a $30 copayment for specialist physician 
services. 
 
You have been asked to pay a $50 copayment for the nasal endoscopy. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to 
pay a $30 copayment for the office visit. This item/service falls within the physician/practitioner services, 
including doctors office visits 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 
the office visit, and the nasal endoscopy provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the eye exam (92014) provided on 
November 29, 2022. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that you contacted the eye clinic and 
were advised that you have had the same exam every year. You also say that you were only responsible for a 
$20.00 copay in both 2020 and 2021. The Plan denied your request. The Plan says  a $30.00 copayment is 
correct according to your Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
 
 
 We looked at the file and the Plan's rules. The contract clearly states that you pay a $30 copay for each 
Medicare-covered exam to diagnose and treat diseases and conditions of the eye. The record shows that you did 
not receive a routine exam, but received a medical exam for multiple diagnoses. 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 reduce the copayment for the eye exam (92014) provided on November 29, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each dialysis treatment provided on 
January 19, 2023, to January 31, 2023. 
 
You asked the Plan to waive the coinsurance for each dialysis treatment. You say that you are on a fixed 
income and cannot afford these payments. 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 20% 
coinsurance for services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for each dialysis treatment. This item/service falls within the 
services to treat kidney disease 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 
each dialysis treatment provided on January 19, 2023, to January 31, 2023.