Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-care/home management training (97535) and therapeutic 
activities, direct (one-on-one) patient contact (97530) provided. 
 
You asked the Plan to pay for the therapeutic and home management training. You say that please see 
additional information regarding service minutes. The Plan denied your request. The Plan says the records do 
not support the billed service. 
 
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 97535 (27 units) and 97530 (2 units) is Self-care/home 
management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety 
procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one 
contact, each 15 minutes and Therapeutic activities, direct (one-on-one) patient contact (use of dynamic 
activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97535 (27 units) and 97530 (2 units) is not supported in the medical record. 
Specifically, the documentation submitted did not include the time spent and do not support the units billed. 
The documentation submitted does not indicate that a total of 15 minutes was spent providing these services. 
There is insufficient documentation to corroborate the services and confirm Medicare coverage has been met. 
The records show that the Plan had made multiple attempts to obtain additional information from the provider 
without success. Based on this information, we decided that Medicare rules for coverage of the therapeutic and 
home management training have not been met. Therefore, we decided that the Plan does not have to pay for 
self-care/home management training (97535) and therapeutic activities, direct (one-on-one) patient contact 
(97530) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manual wheelchair provided to the enrollee on December 
23, 2019. 
 
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 a valid physician order was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The record does not contain a valid physician order. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a manual wheelchair provided to the enrollee on December 23, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), 
with any type side rails, with mattress (CPT Code E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the member needs the bed as 
soon as possible because the member's advanced age, deterioration, dementia and lack of motor skills which 
causes them to fall out of regular beds. The Plan denied your request. The Plan says the Medicare rules have 
not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the semi-electric hospital bed have not been met. We did not see 
documentation of one or more of the criteria listed in the Medicare LCD L33820 in your medical record in 
order to meet medical necessity. Therefore, we decided that the Plan does not have to pre-approve hospital bed, 
semi-electric (head and foot adjustment), with any type side rails, with mattress (CPT Code E0260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided to you by an out-of-network provider 
on June 30, 2020. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 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 the eyewear provided to you by an out-of-network provider on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this device is correct, because 
Medicare does not cover power mobility devices for use solely for convenience outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on July 
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 the enrollee did not have prior authorization for out of network care and the ordering 
physician is not in network. 
 
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 lab services 
provided to the enrollee on July 22, 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 June 24, 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 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 physician services provided 
to the enrollee on June 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no skilled needs qualifying the enrollee for this stay. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventative vaccines provided. 
 
You asked the Plan to pay for preventative vaccines under Medicare Part B. You say that these vaccines should 
be covered by the Plan. The Plan denied your request. The Plan says preventative vaccines are covered under 
Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative 
vaccines under Medicare Part B. The Plan follows the same rules. The records show these vaccines were 
preventative in nature. Therefore, we decided that the Plan does not have to pay for preventative vaccines 
provided.  
 
Benefits for preventative vaccines may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services provided to the enrollee on December 6, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that laboratory results have not been submitted for the billed date of service. 
 
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 the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
HCPCS G0482: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed 
 
 
 
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 services. Our reviewers says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found in this case 
the documentation indicates that the lab studies were obtained on the date in question December 6, 2019. The 
review has determined that the records support the coding of the above denied codes. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
drug testing services provided to the enrollee on December 6, 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 a skilled nursing visit provided to the enrollee out of network 
on February 21, 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 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 a skilled nursing visit 
provided to the enrollee out of network on February 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from August 10, 2020, to August 12, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you shouldn't have 
to pay this copayment because you were in another facility from July 31, 2020 to August 10, 2020.  You said 
that you had to be transferred for testing that couldn't be provided at the first facility. The Plan denied your 
request. The Plan says you were charged this copayment correctly because these copayments are charged per 
admission. 
 
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 $380 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $380 copayment per day for the inpatient hospital services. Copayments for 
inpatient hospital services are charged per admission, regardless of the reason for the admission.  You had two 
separate admissions, so two copayments apply. 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 inpatient 
hospital services you received from August 10, 2020, to August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on July 30, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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. 
 
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 
psychotherapy services. 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 psychotherapy services provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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. 
 
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 
physician?s services. 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 physician's services provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on April 
30, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that this was the only 
ambulance service provider in your area. You say that you are disputing the charge. The Plan denied your 
request. The Plan says the copayment 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 $270 
copayment per date of service regardless of the number of trips. 
 
You have been asked to pay a $270 copayment for the ambulance transport. The ambulance transport falls 
within the "Ambulance 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 
the ambulance transport provided on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections (J0129, J2920, J1030 and 
J1885) provided on May, 5 2020, May 27, 2020, and June 4, 2020. 
 
You asked the Plan to waive the coinsurance for injections. You say that you should not be responsible for any 
cost share. The Plan denied your request. The Plan says the coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for injections. This service falls 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 coinsurance for injections (J0129, 
J2920, J1030 and J1885) provided on May, 5 2020, May 27, 2020, and June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse the copayment for chiropractic services provided on June 
30, 2020, and July 14, 2020. 
 
You asked the Plan to reimburse the copayment for chiropractic services. You say that you disagree with the 
amount you were reimbursed. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for chiropractic services.  
 
You received chiropractic services on June 30, 2020, and July 14, 2020. Therefore, you are responsible to pay a 
$20 copayment per each service. The total amount you owe is: $40. Please contact the provider with any 
questions regarding overpayments or refunds.  
 
You have been asked to pay the total copayment amount of $40 for chiropractic services. Chiropractic services 
fall within the chiropractic 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 reimburse the copayment 
for chiropractic services provided on June 30, 2020, and July 14, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pre-operative echocardiogram provided on June 2, 2020. 
 
You asked the Plan to pay for echocardiogram. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because this test is not covered 
pre-operatively when there are no indications for the test. 
 
The Plan must follow Medicare rules. Medicare rules say that pre-operative testing without additional 
diagnoses indicating medical necessity will be denied.  
 
We looked at the file and Medicare rules. This testing was provided pre-operatively without additional 
diagnoses otherwise indicating medical necessity. Based on this information, we decided that Medicare rules 
for coverage of echocardiogram have not been met. Therefore, we decided that the Plan does not have to pay 
for a pre-operative echocardiogram provided on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 23, 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 screening tests are not covered. 
 
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, a cardiovascular risk assessment panel, 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 the laboratory services rendered on May 23, 2020.