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

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on July 15, 2020 
and July 23, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you are on a fixed income and 
this should be covered in full. The Plan denied your request. The Plan says the copayments were applied 
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 $40 
copayment for each Medicare-covered therapy visit.  
 
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $80 
($40/visit x 2 visits = $80). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided on July 15, 2020 and 
July 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided from May 8, 2020, to May 11, 
2020. 
 
You asked the Plan to pay for critical care. You say that this code is documented in the records. The Plan 
denied your request. The Plan says this code 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document 
the time spent on this service. Without this information, this code cannot be verified. Based on this information, 
we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the 
Plan does not have to pay for critical care (99291) provided from May 8, 2020, to May 11, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are in an inpatient acute facility and about to be 
discharged with nowhere to go for appropriate care. The Plan denied your request. The Plan says rules for SNF 
care have not been met. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. You do not, however, require skilled nursing 
or therapy services on a daily basis. You do 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray you had on July 27, 2020. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you shouldn't have to pay this 
copayment since you had this same test three weeks before. 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 $40 
copayment for basic imaging services.  
 
You have been asked to pay a $40 copayment for the x-ray. The x-ray falls within the basic imaging services 
benefit category. This copayment applies regardless of the reason for the test. 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 x-ray you had on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power 
options for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the coverage criteria for power tilt or recline. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation is conflicting on the enrollee's function. The 8/4/20 physician notes indicates  normal gait, 
normal sensation and reflexes, normal musculoskeletal exam of extremities, no joint pain, cervical and lumbar 
spine exam normal, and normal neurological exam. It is not clear that the enrollee has a personal mobility 
deficit that impairs participation in MRADLs in the home given conflicting information. The enrollee's 
mobility deficit is helped currently by a rollator with rest breaks. The documentation is conflicting on whether 
the enrollee can safely operate a power mobility device. The physician notes indicates memory impairment 
which could indicate poor carryover of wheelchair instruction use. The wheelchair evaluation states cognition 
intact. Given the conflicting documentation it is not clear that the enrollee requires the requested wheelchair 
with multiple power options. Furthermore, the documentation does not support she is unable to perform a 
functional weight shift, uses intermittent catheterization for bladder management, or needs the power seating 
system for increased spasticity. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 power wheelchair with multiple power options for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forground transport mileage (A0425) provided April 13, 2020.You asked the Plan to pay forthe mileage. You say that the transport was medically necessary.The Plan denied your request. The Plan says the units billed exceeds the allowable amount.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code A0425 is 250. You billed 290 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the mileage have not been met.Therefore, we decided that the Plan does not have to pay forground transport mileage (A0425) provided April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on July 4, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on July 4, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on October 17, 
2019. 
 
You asked the Plan to pay for the moderate sedation services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the documentation submitted does not support moderate sedation 
services. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. The CPT Code Manual definition of code 99153 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)   
 
We find that CPT code 99152, 99153 is not supported in the medical record. Specifically, the Operative Report 
 
 
submitted has a different date of service than the claim date of service. Based on this information, we decided 
that Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that 
the Plan does not have to pay for the moderate sedation services provided on October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on May 26, 2020. 
 
You asked the Plan to pay for the refraction. You say that  The Plan denied your request. The Plan says this is 
not covered by the 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.  
 
Though the Plan offers a vision benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
refraction provided on May 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services and mileage provided on May 26, 
2020. 
 
You asked the Plan to pay for the air ambulance services and mileage. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the claim was processed correctly. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We looked at the file and Medicare rules. Review of the file shows that transport is covered when it would take 
a ground ambulance 30-60 minutes or more to transport a beneficiary. It would have been feasible to transport 
the safely patient via critical care ground ambulance in 26 minutes. In addition, the plan has approved and paid 
the critical care ground transport rates between facilities. Based on this information, we decided that Medicare 
rules for coverage of the air ambulance services and mileage have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance services and mileage provided on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional acupuncture visits. 
 
You asked the Plan to pre-approve the twelve (12) additional acupuncture visits. The Plan denied your request. 
The Plan says an additional 12 visits beyond the 20 allowed visits exceeds the allowable benefit. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, visits beyond the 20 allowed visits exceeds the 
allowable benefit. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional 
acupuncture visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on May 2, 2020 
through May 31, 2020. 
 
You asked the Plan to pay for SNF care. You say that the services rendered were medically necessary. The Plan 
denied your request. The Plan says custodial services are services that can be provided safely and reasonably 
by someone without medical, nursing or other professional training. Medicare does not cover these types of 
non-skilled care. 
 
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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy 
service needs and the beneficiary does not require skilled nursing or therapy services on a daily basis.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided on May 2, 2020 through May 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrollee in hospice on this date. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the services provided on May 13, 2020.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to pre-approve the Keytruda injections. We decided that the Plan does not have to 
pre-approve the oral cabozantinib.  
 
You asked the Plan to pre-approve the Keytruda injections. You say that this should be approved as it is 
standard of care. The Plan says that the use of this treatment is experimental at this time. 
 
We decided that the Plan has to pre-approve the Keytruda injections.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda injections. Our reviewer 
says that the requested use of Keytruda is medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of oral squamous cell carcinoma with metastasis. He has undergone 
prior chemotherapy along with surgery. He now has findings of metastases to the lungs and bone. Keytruda is 
FDA-approved as a single-agent for treatment of recurrent or metastatic head/neck squamous cell carcinoma in 
patients with disease progression on or after platinum-containing chemotherapy. This enrollee had progression 
of disease after use of a platinum agent which meets the criteria for treatment with Keytruda. 
 
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 Keytruda injections have been met. Therefore, we decided that the Plan has 
to pre-approve the Keytruda injections.  
 
We also decided that the Plan does not have to pre-approve the oral cabozantinib. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. 
 
This oral anti-cancer drug does not have a non-self-administered (injectable) form. As such, it is not among the 
self-administered drugs that can be covered by Medicare Part B. Therefore, we decided that the Plan does not 
have to pre-approve the oral cabozantinib. 
 
Benefits for oral cabozantinib may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic shoes and inserts rendered. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic shoes and inserts rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision evaluation provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for vision evaluation. You say that the doctor should not be held responsible for 
receiving prior authorization. The Plan denied your request. The Plan says prior authorization must be obtained 
for non-emergent services 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 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 vision evaluation provided by an out of network
 (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital laboratory services provided on January 
13, 2020. 
 
You asked the Plan to pay for the outpatient hospital laboratory services. The Plan denied your request. The 
Plan says prior authorization was not obtained by the provider or facility. 
 
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 outpatient hospital laboratory services provided on January 13, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 9, 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 procedure codes 80157, 80177, 80201, 80162, 80159 and 80173 are 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical 
record. Specifically, there is no documentation of the testing performed via blood sampling. 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 the laboratory services rendered on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that NGS panels must be billed with procedure code 
81479. 
 
The file shows that the NGS panel was not billed with code 81479 but as a panel of codes. 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 the laboratory services rendered on February 18, 2020.