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

 
We decided that the Plan does not have to pay for the services provided on May 28, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice on the date of service in question. 
 
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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the services provided on May 28, 2019.
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 May 21, 2020, to May 23, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that this copayment 
should be waived because your condition was due to your doctor's negligence. The Plan denied your request. 
The Plan says it has waived the cost sharing for the outpatient surgery services you received on June 3, 2020.  
However, the Plan says you were charged the inpatient hospital cost sharing correctly for dates of service May 
21, 2020, to May 23, 2020. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment per day for days 1-4 for inpatient hospital care.  
 
You have been asked to pay a $295 copayment per day for the inpatient hospital services. 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 May 21, 2020, to May 
23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a treadmill. 
 
You asked the Plan to pre-approve the treadmill. You say that you would like reconsideration because the 
treadmill therapy will help you to walk without pain. The Plan denied your request. The Plan says this is not a 
Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a treadmill.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient stay surgery (panniculectomy). 
 
You asked the Plan to pre-approve the services. You say that your stomach is hanging over due to weight loss 
and think it is what is causing the rash. The Plan denied your request. The Plan says that they do not see that 
have/or had problems with extra skin on your abdomen and not gotten better with non-surgery treatment (skin 
ulcers, infections, rashes), or that the extra skin interferes with your daily activities. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found review of the medical records and photographs support that you would likely benefit from 
surgical correction in the form of panniculectomy. From Medicare, Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. Thus, inpatient panniculectomy satisfies Medicare medically 
necessary criteria. An inpatient admission may be necessary depending on intra-operative findings, as well as 
post-procedure clinical findings. 
 
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 pre-
approve inpatient stay surgery (panniculectomy).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lipiflow Thermal Pulsation System. 
 
You asked the Plan to pre-approve the Lipiflow Thermal Pulsation System. You say that the enrollee has had 
success with this treatment in the past. The Plan denied your request. The Plan says this device is considered 
investigational at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare does not cover the Lipiflow Thermal Pulsation System. 
Therefore, we decided that the Plan does not have to pre-approve the Lipiflow Thermal Pulsation System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that this feature is a medical necessity 
for you. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because 
a power seat elevation feature is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered by 
Medicare because it is not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation feature for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided to the enrollee on January 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says it cannot be 
determined how the enrollee came to the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not 
contain medical records. Without records, it cannot be confirmed that Medicare coverage criteria have been 
met. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on 
January 3, 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 30, 2019 and 
billed under codes G0481 and 80307. 
 
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 the records provided do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on April 30, 2019 and billed 
under codes G0481 and 80307.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF care.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.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 there is no documentation to support that the enrollee requires any skilled nursing or rehab services on a daily basis at an inpatient level of care. The enrollee is not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee does not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee does not require any skilled services on an inpatient basis, at a SNF level of care. The enrollee does not have any parental medication, complex wound care or nutrition given via a feeding tube. Admission to a skilled nursing facility for inpatient skilled rehab or nursing services is not medically 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee. 
 
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 based on the medical records provided, code 64493 was performed by the provider on 
different regions, the appropriate modifier has not been billed to show that these procedures were distinct and 
independent to one another on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Providers may bill services with a modifier if 
the service billed indicates a distinct procedural service. The medical records provided do not show that the 
service billed with the required modifier. Medicare rules for coverage of this service are not met. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the established patient office or other outpatient (99214) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the established patient office or other outpatient. You say that you have seen 
this doctor before and that they speak Chinese. The Plan denied your request. The Plan says the requested 
service can be provided in-network. In addition, the plan has indicated that there is an in-network 
ophthalmologist who can speak Chinese. 
 
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 
the established patient office or other outpatient (99214) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
provided before the end of the month in which hospice services were discontinued. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided 
to the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on 
July 6, 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 CPT code 99212 (Office or other outpatient visit for the evaluation and management of 
established patient), denied because the evaluation and management service were billed with an incorrect place 
of service (23). Per the AMA CPT manual, CPT code 99212 is used to report evaluation and management 
services provided in the office or in an outpatient or other ambulatory facility. The emergency department, as 
defined per CMS Medicare Claims Processing Manual 30.6.11.B, is an organized hospital-based facility for the 
provision of unscheduled or episodic services to patients who present for immediate medical attention.  Per 
Medicare Claims Processing Manual 30.6.11 C, the only scenario for which the physician should bill an 
office/outpatient visit code while the patient is in the emergency department is if the physician asks the patient 
to meet him or her in the ER as an alternative to the physician's office and the patient is not registered as a 
patient in the emergency room. Per review of the submitted documentation, the enrollee presented to the 
emergency room for higher level of psychiatric care. There is no indication the enrollee was directed to meet a 
specific provider. Therefore, code 99212 was billed in error.  
 
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 99212 not supported by the Medical records. Medicare rules for coverage of this service have not been 
met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided to 
the enrollee on July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF 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 requestedIRF 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, or to be able to perform, fifteen hours per week of rehabilitative services with 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-approveacute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.

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 not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the complex chronic care management services (99487) provided on June 19, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the complex chronic care management services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.

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 complex chronic care management services (99487) provided on June 19, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology service provided. 
 
You asked the Plan to waive the copayment for the ophthalmology services. You say that you went in for a 
routine vision exam which should have no copayment. The Plan denied your request. The Plan says you have a 
specialist copayment and you were charged the 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 $35 
copayment for Vision Care, Specialist's Office.  
 
You have been asked to pay a $35 copayment for the ophthalmology services. The ophthalmology service falls 
within the Vision Care, Specialist's Office, 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 ophthalmology services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5257) purchased from an out of network 
provider on May 14, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that You wish to appeal the denial of your claim for 
hearing aids. You believed that the plan would pay $500 towards your hearing aids. You did not know that you 
needed approval. The Plan denied your request. The Plan says enrollee's must receive their hearing services 
from an in-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5257) purchased from an out of network provider on May 14, 2020.