Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the pulmonary rehabilitation services 
provided on February 6, 2020. 
 
You asked the Plan to waive the deductible the pulmonary rehabilitation services. You say that you will not pay 
this bill. The Plan denied your request. The Plan says you had not yet met the deductible as of the date of 
service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1250 deductible. The deductible applies to the pulmonary 
rehabilitation services in question. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $1250 deductible that applies to the services in question in this appeal. This cost sharing is a 
contractual obligation that had not been met at the time the pulmonary rehabilitation services were received on 
February 6, 2020. Therefore, we decided that the Plan does not have to waive the deductible for pulmonary 
rehabilitation services provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 29, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) A9900-NU is included in the 
payment of the other services performed on the same date of service, for the same patient, and by the same 
provider and is not separately reimbursable.   
 
The Plan says that this code has a Status Indicator of "X". There are no RVUs and no payment amounts for 
these services. No separate payment should be made for them under the fee schedule.  
 
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, code A9900-NU cannot be paid 
separately as billed based on the bundled relationship with other services performed on the same day. Medicare 
rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services provided to the enrollee on January 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the stress test and echocardiogram you had 
on May 7, 2020. 
 
You asked the Plan to waive the copayment for the stress test and echocardiogram. You say that you thought 
these were being performed in an office, so you budgeted for an office visit copayment. The Plan denied your 
request. The Plan says you were charged this copayment 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 $100 
copayment for diagnostic procedures and tests in an outpatient hospital facility.  
 
You have been asked to pay a $100 copayment for the stress test and echocardiogram. The stress test and 
echocardiogram fall within the diagnostic procedures and tests in an outpatient hospital facility benefit 
category. The provider billed this on an institutional, not physician, claim form.  The provider billed this as an 
outpatient hospital service. 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 stress test and 
echocardiogram you had on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CMT provided on January 20, 2020 by an OON provider. 
 
You asked the Plan to pay for the CMT. You say that the services were medically necessary due to the nature 
of the enrollee's condition. The Plan denied your request. The Plan says the services were rendered by a non-
participating provider. The Plan also says that the services were not urgent or emergent in nature, and the 
services were not authorized by the Plan. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the CMT provided on January 20, 2020 by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 12, 
2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 12, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient radiological diagnostic services 
received on May 05, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you want the copayment waived. The 
Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and 
the services rendered. 
 
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 $105 
copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $105 copayment for the services. The services fall within the Medicare-covered 
radiological diagnostic 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 
outpatient radiological diagnostic services received on May 05, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystourethroscopy procedure you had 
on May 22, 2020. 
 
You asked the Plan to waive the copayment for the cystourethroscopy procedure. You say that no one has been 
able to explain these charges to you. The Plan denied your request. The Plan says you were charged this 
copayment 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 $325 
copayment for surgical services in an outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for the cystourethroscopy procedure. The cystourethroscopy 
procedure falls within the surgical services in an outpatient hospital facility 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 cystourethroscopy procedure you had at Regional One, an 
outpatient hospital facility, on May 22, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute 
care on 10/16/20 with hyponatremia and recent pelvic and thoracic/lumbar fractures. From a nursing 
perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for 
hyponatremia. Regarding rehabilitation services, the enrollee received physical therapy and occupational 
therapy in the acute hospital. The enrollee was at supervision/touch assist level with functional mobility 
including gait to 200 feet with a rolling walker. She required varying assist with activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 21, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for wound therapy pump. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of payment for this item is correct, because this provider is out-
of-network with the Plan and the referring provider is also out-of-network with the Plan. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on October 21, 2019 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of hypertension and Parkinson's disease who was admitted to the acute hospital on 09/30/2020 
with quadriparesis worse in the lower extremities due to C3-C4 spinal stenosis. He was treated in the hospital 
with surgical decompression and fusion of the involved cervical vertebrae. Post-operatively he was treated for 
deep vein thrombosis and pulmonary embolus and hyponatremia. He is weak and deconditioned and is working 
with physical and occupational therapy. He has an Aspen collar and cervical spine precautions. He is walking 
270 feet with minimum assistance and a rolling walker and is minimum to moderate assist for transfers and 
minimum to moderate assist for activities of daily living. He is reported to be medically stable for discharge. 
Transfer to an acute inpatient rehabilitation facility is requested.  
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no 
documentation demonstrating that the enrollee requires the intensive rehabilitation therapy program provided in 
an inpatient rehabilitation facility. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission rendered from 
April 19, 2020 to May 18, 2020. 
 
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 the enrollee exhausted the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from October 7, 2019 
to April 18, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing facility (SNF) admission rendered from April 19, 2020 
to May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a MyoPro Motion G Limb orthosis (L8702). 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says this service is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say items that are experimental and investigational are 
not covered. A review of the current medical literature indicates that this service is considered experimental 
and investigational as it is not identified as widely used and generally accepted for the proposed use as reported 
in nationally recognized peer-reviewed medical literature published in the English language. The Medicare 
guidelines say that this item or service is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for a MyoPro Motion G Limb orthosis (L8702).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not 
have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not 
require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a 
SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99350) provided on August 9, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the billed code does not appropriately reflect the 
services provided. 
 
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 99350 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval 
history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a 
significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99350 is not supported in the record. Specifically, the record indicates that these 
services were rendered by a licensed vocational nurse. There is no evidence that the billing physician was 
present in the beneficiary's home. Based on this information, we decided that Medicare rules for coverage of 
the home visit have not been met. Therefore, we decided that the Plan does not have to pay for the home visit 
(99350) provided on August 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient behavioral health hospital stay. 
 
You asked the Plan to pre-approve the inpatient stay. You say that you would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the member could be treated 
safely and effectively at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient stay. Our reviewer says 
that the member does not meet the criteria for treatment in an acute inpatient mental health treatment beyond 
the date in question of October 7, 2020 forward and could have been treated in a lesser restrictive setting. Our 
physician reviewer found the member was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations or delusions and was not showing any behaviors or aggression. The member was being 
cooperative and compliant while not showing any acute threats to safety. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an inpatient behavioral health hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
19, 2020. 
 
You asked the Plan to pay for the dental service. You say that the service should be covered. You say that at 
your previous visit they did not do a whole oral exam. You say that they only did a partial exam for 1 tooth. 
The Plan denied your request. The Plan says 1 oral exam is covered every 6 months. The Plan also says that the 
frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and oral exams are a covered service, 
the frequency limit has been exceeded. The record shows that you received a limited oral evaluation on June 5, 
2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on June 19, 2020.