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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from December 20, 2019, 
through December 27, 2019. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided 
was medically necessary for the enrollee.  The Plan denied your request. The Plan says that the inpatient 
hospital care provided was not medically necessary.  
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the patient with multiple chronic medical problems was admitted with weakness 
and mild acute renal failure (ARF). He was a fall risk. The patient required intravenous fluids and was thought 
to need skilled nursing facility care at the time of admission. It was reasonable to believe with chronic health 
problems, a fall risk at home, and failure to thrive, that the patient?s necessary hospital care would span two 
midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from December 20, 2019, through December 27, 
2019.  
 
 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out 
of network provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary and performed 
in good faith. The Plan denied your request. The Plan says you did not request 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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 the medical services provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at 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 IRF care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral facet injection (L3-L5) for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no physical assessment documented since 2017. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there needs to be an in-person physical exam to clearly document the source of the pain. Therefore, the 
request at this time is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bilateral facet injection (L3-L5) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 17, 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 although the enrollee has a diagnosis of recurrent advanced cancer, his current treatment 
has been effective for over 12 months, is currently tolerated, and the records show no plans to adjust treatment 
based on testing results. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the records provided do not show the 
enrollee met the required coverage criteria for this testing at the time of service. Medicare rules for coverage of 
this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided by a 
participating provider on July 23, 2020, on July 23, 2020. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you would like this 
copayment waived. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $385 
copayment for outpatient surgery/other services provided in hospital.  
 
You have been asked to pay $127.81 which is less than your copayment amount of $385 for an outpatient 
hospital visit. An outpatient hospital visit falls within the outpatient surgery/other services provided in hospital 
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 outpatient hospital visit 
provided by a participating provider on July 23, 2020, on July 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says you are independent with the home exercise program. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the medical records provided, there is no documentation that 
the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the 
available records, you appear to be near plateau with therapy. Further therapy beyond the approved 16 
additional sessions at this point does not appear to be likely to achieve any significant improvement in your 
symptoms or functional status. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like approval for this specific 
provider. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical dressings. 
 
You asked the Plan to pre-approve the surgical dressings. You say that the dressings are medically necessary 
because the enrollee has a planned hernia repair surgery. The Plan denied your request. The Plan says coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that surgical dressings are covered for a wound 
caused by, or treated by, a surgical procedure.  
 
We looked at the file and Medicare rules. The record shows that the enrollee has not yet had the surgical 
procedure. Based on this information, we decided that Medicare rules for coverage of the surgical dressings 
have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical dressings.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $325 copayment charged for ambulance transport 
provided on July 20, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement. 
 
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 $325 
copayment for ambulance transport. 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 $325 copayment charged for ambulance 
transport provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 18, 2020. 
 
You asked the Plan to pay for the office visit (99214). You say that the enrollee had several services on this 
date with different providers. The Plan denied your request. The Plan says this procedure was reported for the 
same service on the same day by the same provider. 
 
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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires at least 2 of these 3 key components: A detailed 
history; A detailed examination; Medical decision making of moderate 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. Typically, 25 minutes are spent face-to-face with the patient 
and/or family.  
 
We find that CPT code 99214 is not supported in the medical record. Specifically, there is only one medical 
record in the case file, of an office visit with this provider, on this day of service. A claim was paid for this 
provider for procedure 99215. Based on this information, we decided that Medicare rules for coverage of the 
office visit 99214 have not been met. Therefore, we decided that the Plan does not have to pay for the office 
visit provided on February 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee 
from June 23, 2020, to July 9, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee from June 23, 2020, to July 9, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound, breast, unilateral, real time with image 
documentation, including axilla when performed (76641) provided June 18, 2020. 
 
You asked the Plan to pay for the breast ultrasound. You say that your gynecological office had long ago 
advised you needed the ultrasounds as they are medically necessary. You are requesting that the Plan pay the 
$125.17 patient balance on the bill. The Plan denied your request. The Plan says the total allowed amount for 
the services of $127.17 was applied towards the $1000 deductible. 
 
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 $1000 deductible.  
 
The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests 
and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $1000 deductible. This is the amount you have to pay out-of-pocket before the plan will 
pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the 
full cost for most of your covered services. This cost sharing is a contractual obligation that had not been met at 
the time the breast ultrasound was received on June 18, 2020. Therefore, we decided that the Plan does not 
have to pay for ultrasound, breast, unilateral, real time with image documentation, including axilla when 
performed (76641) provided June 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's condition is not improving. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the available records, the patient appears to have plateaued 
with therapy. In addition, he is significantly limited by fatigue. Further therapy at this point does not appear to 
be likely to achieve any significant improvement in the patient's symptoms or functional status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued physical therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on December 3, 
2019. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says these services are not authorized because molecular genetic screening testing is not a 
Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes. Medicare non-
coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed 
care. Any and all codes on this claim are denied, and in addition, previous payments to this provider for this 
enrollee are subject to recoupment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the codes submitted for payment are 
excluded from Medicare coverage for the diagnosis code billed. Screening molecular testing is not covered.  
Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on 
December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the device is medically necessary. The 
Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that ventilators are covered when medically necessary. 
 
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 portable ventilator. Our reviewer 
says that the requested device is not medically necessary. Our physician reviewer found the order is for the 
Life2000 respiratory support system. This is not a true portable ventilator. It is intended for use during activity, 
while awake, and involves positive pressure oxygen. There is insufficient evidence to conclude that this device 
is beneficial in patients with COPD. The patient also does not meet coverage criteria for a true portable or 
home ventilator. BiPAP has not been trialed. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection, golimumab, 1 mg (J1602) 
provided June 25, 2020. 
 
You asked the Plan to waive the copayment for the injection services. You say that you were misinformed by 
the doctor's office that your copayment for these services was only $25. The Plan denied your request. The Plan 
says the claim has been processed and the correct copayment was applied per the plan benefits. 
 
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 chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B.  
 
You have been asked to pay $806.88 for the injection services. ($3832.68 x 20% = $766.54 and $201.72 x 20% 
= $40.34. $766.54 + $40.34 = $806.88).  The injection services 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 waive the copayment for injection, golimumab, 1 mg 
(J1602) provided June 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 22, 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 this testing was done for screening services which is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The test at issue in this appeal, this service, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for lab services provided to the enrollee on April 22, 2020.