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

We decided that the Plan does not have to pay for massage therapy and electrical stimulation provided on 
January 7, 2020. 
 
You asked the Plan to pay for massage therapy and electrical stimulation provided by a chiropractor. You say 
that the Plan should pay this claim. The Plan denied your request. The Plan says these services are not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for massage therapy and electrical stimulation provided on January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for outpatient hospital clinic visits provided. 
 
You asked the Plan to waive the co payment for the outpatient clinic visits. You say that the manner in which 
your treatments were billed is inconsistent. All of your visits were for the same ailment and each treatment was 
the same. The Plan denied your request. The Plan says these claims were processed with the correct 
co payments 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 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 
co payment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $720 for the outpatient clinic visits. You received outpatient services at a hospitaL. 
Therefore, you were charged 
$250 for date of service and would have been charged $250 co payment also but the allowable was $156.74.
; therefore, you were only charged $156.74 instead of $250 for those dates. 
$250 + $156.74 + $156.74 + $156.74 = $720.22. The outpatient clinic visits fall within the Outpatient surgery 
and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for outpatient hospital clinic visits provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthosis rendered on June 10, 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 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 the orthosis rendered on June 10, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a transcatheter aortic valve replacement (TAVR) procedure. 
 
You asked the Plan to pre-approve the TAVR procedure. You say that this is a medically necessary procedure 
and should be covered by the Plan. The Plan denied your request. The Plan says that the enrollee needs to be in 
a clinical study for this to be covered. 
 
Please note that the Plan's rationale regarding the need to be enrolled in a clinical study, rather than a 
registry, only applies to use of the TAVR procedure for non-FDA-approved indications, according to the 
language of the NCD. 
 
The Plan follows Medicare rules. Medicare rules say that TAVR, when provided for an FDA-approved 
indication, is covered by Medicare when the facility meets certain qualifications and participates in a national 
clinical registry. 
 
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 TAVR procedure. Our reviewer 
says that the requested procedure is considered medically necessary and will be provided according to the NCD 
rules. Our physician reviewer found the patient has severe symptomatic aortic valve stenosis with mean aortic 
valve gradient close to 40mmHg and severely reduced aortic valve area (0.74-0.83cm2). In addition, the patient 
is under the care of a multidisciplinary valve team in a university hospital that is participating in a prospective, 
national, audited registry. Coverage criteria are met in this case. 
 
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 TAVR procedure have been met. Therefore, we decided that the Plan has to 
pre-approve a transcatheter aortic valve replacement (TAVR) procedure.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from December 4, 2020, 
forward. 
 
You asked the Plan to pre-approve SNF 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 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 are identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing 
or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a SNF 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 continuation of SNF care from December 4, 2020, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 11, 2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
that the Plan requires utilization of network providers when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.    
 
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 subsequent nursing facility care provided on April 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that your oncologist recommended a 
consultation with this provider for possible stem cell therapy or other therapy. The Plan denied your request. 
The Plan says your plan covers providers outside of your network only when your medical needs cannot be met 
in your network. The Plan states your provider did not provide records that show this is the case for you. 
 
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing (81210, 81323, 81405, 81406, 81407, 
81408, 81479) provided on January 23, 2020. 
 
You asked the Plan to pay for laboratory testing. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for laboratory testing (81210, 
81323, 81405, 81406, 81407, 81408, 81479) provided on January 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from March 25, 2020, 
through April 21, 2020. 
 
You asked the Plan to pay for the home health services. You say that this should be paid. The Plan denied your 
request. The Plan says this was not correctly billed with the Q-code for home health services. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must report a Q-code along 
with the first visit reported on the claim to indicate the location the services were rendered.  
 
In this case, the first visit reported on this claim was a nurse visit on March 25, 2020. However, the code 
Q5001 was reported along with services for the next date of service, on March 29, 2020. Since the Q-code was 
not reported for the appropriate date, this claim is not billed correctly. Therefore, we decided that the Plan does 
not have to pay for the home health services provided from March 25, 2020, through April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on April 2, 2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 
non-emergent services provided by non-participating facilities require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
hospital outpatient clinic visit. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on April 
2, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 14, 2020. 
 
You asked the Plan to pay for the physician service. You say that the service provided is not related to the 
reason that the enrollee is in hospice. You also say that you received a letter from hospice advising to bill the 
insurance. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the 
member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
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 office visit provided on May 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, 
tomographic (SPECT) multiple studies, at rest and/or stress and/or redistribution and/or rest reinjection (78452) 
technetium tc-99m sestamibi, diagnostic, per study dose (A9500) provided December 3, 2019. 
 
You asked the Plan to waive the copayment for the diagnostic services. You say that you were not aware of 
having to get personal referrals to specialists. The Plan denied your request. The Plan says this claim was 
processed with the correct copayment 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 $100 
copayment for each Medicare covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a free standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $100 copayment for the diagnostic services. The diagnostic services fall within the 
Outpatient diagnostic test therapeutic services and supplies 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 myocardial perfusion imaging, tomographic (SPECT) multiple studies, at rest 
and/or stress and/or redistribution and/or rest reinjection (78452) technetium tc-99m sestamibi, diagnostic, per 
study dose (A9500) provided December 3, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency services provided on 
February 16, 2020. 
 
You asked the Plan to waive the copayment for the emergency services. You say that you were only there a few 
minutes so you shouldn't have to pay the copayment. The Plan denied your request. The Plan says 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 $110 
copayment for Emergency Care. 
 
You have been asked to pay a $110 copayment for the emergency services. The emergency service falls within 
the Emergency Care 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 emergency 
services provided on February 16, 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 May 14, 2020, to May 17, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were in a 
different hospital for gall bladder surgery, but you had to be transferred because you needed surgical services 
not available at the first hospital.  You say that you shouldn't have to pay a copayment for the second hospital. 
The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-6 for inpatient hospital care.  
 
Records show that you were in observation status at the first hospital from May 13, 2020, to May 14, 2020.  
 You were not admitted to that hospital as an inpatient.  When you were transferred to the second hospital, you 
were admitted as an inpatient. You have been asked to pay a $325 copayment per day for days 1-6 for each day 
of your 3-day inpatient hospital stay from May 14, 2020, to May 17, 2020. You were not assessed an inpatient 
copayment for the first stay. Rather, you were charged the appropriate cost sharing for observation care, which 
is different than inpatient care.  This means that you have been asked to pay the correct amount for the second 
stay 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 14, 2020, to May 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient services provided from 
February 14, 2020, to February 18, 2020. 
 
You asked the Plan to waive the copayment for the inpatient services. You say that you do not have the means 
to pay the copayment. The Plan denied your request. The Plan says 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 $295 
copayment per day for days 1-5 for Inpatient Hospital Care.  
 
You have been asked to pay a $295 copayment per day for days 1-5 for the inpatient services. The inpatient 
services fall within the Inpatient Hospital Care 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 inpatient services provided from February 14, 2020, to February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to admission to an inpatient rehabilitation 
facility (IRF) for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no diagnosis appropriate for acute rehab. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for urinary tract infection and sepsis. Medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 admission to admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3. 
 
You asked the Plan to pre-approve the core build up. You say that the enrollee has restorations with recurrent 
caries on tooth # 3. The Plan denied your request. The Plan says core build up is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for tooth # 3.