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

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared 
for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the 
enrollee has not completed the full course in the hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee as admitted to the hospital due to an infected foot wound. The hospital course 
was complicated by osteomyelitis requiring surgical intervention, as well as kidney injury, bowel dysfunction 
and severe pain. The enrollee still requires acute hospital level of care services and is receiving appropriate care 
at the present acute care hospital. She does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80307, G0483) provided October 3, 
2019. 
 
You asked the Plan to pay for laboratory services. You say that you would like reconsideration based on the 
medical records provided. The Plan denied your request. The Plan says the billed services were not supported. 
 
The Plan must follow Medicare rules. The rules say that the POS code generally used reflects the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the record shows that the enrollee received the 
face to-face service in an office setting. The POS billed was for independent laboratory. Therefore, we decided 
that the Plan does not have to pay for laboratory services (80307, G0483) provided October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a radiological diagnostic service provided 
by a participating provider on May 7, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you do not agree with this. The 
Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $155 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay a $155 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests/radiological diagnostic 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 a radiological diagnostic service provided by a participating provider on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for Cast supplies, short arm cast, adult (11 years +), fiberglass (Q4010) 
provided on March 30, 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 that the records do not support the services billed. 
 
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 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 this service. Our reviewers said that Medicare coverage criteria are met. Our physician 
reviewer found Per documentation the treatment plan was recorded as "Treatment Plan: Ulnar gutter cast.  
Elevate for swelling.  We will see him back in 3 weeks, remove the cast and get a three-view right hand x-ray". 
The records provided support the services billed. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of this service have been met. 
Therefore, we decided that the Plan has to pay for Cast supplies, short arm cast, adult (11 years +), fiberglass 
(Q4010) provided on March 30, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment performed on May 22, 2020. 
 
You asked the Plan to pay for cardiovascular risk assessment. You say that the Plan should pay for this service. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
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, cardiovascular risk assessment, 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 cardiovascular risk assessment performed on May 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided on July 13, 2020. 
 
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your 
request. The Plan says this was not billed with the required modifier. 
 
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, we have confirmed that code 71045 
has a Column One/Column Two relationship with code 32555, which was previously billed and paid, and 
cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier to 
indicate it is a separate service. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on July 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided to the enrollee March 20, 2020 and 
billed under code 81408. 
 
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 Medicare coverage criteria were not met. 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 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 this service. Our reviewer says that 
Medicare coverage criteria are not met. Our physician reviewer found the documentation submitted was 
reviewed and does not meet criteria. Per Medicare Comprehensive Genomic Profile (CGP) testing requires the 
use of Common Procedural Terminology (CPT) 81479 with the appropriate DEX Z-Code identifier.  The Z-
codes are required for Tier l and Tier 2 Molecular 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pay for testing services provided to the enrollee March 20, 2020 and billed under code 81408.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography (93312, 93320) provided on December 10, 
2019. 
 
You asked the Plan to pay for echocardiography. You say that these codes are supported in the records. The 
Plan denied your request. The Plan says only one unit of each code is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional units of CPT codes 93312 and 93320 are not supported in the medical record. The 
medical record only supports one unit of each CPT code 93312 and 93320, which was previously billed and 
paid. Based on this information, we decided that Medicare rules for coverage of echocardiography have not 
been met. Therefore, we decided that the Plan does not have to pay for echocardiography (93312, 93320) 
provided on December 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home physical and occupational therapy services 
provided on March 18, 2020 billed with codes S9129 and S9131. 
 
You asked the Plan to pay for the therapy services. You say that this should be covered due to medical 
necessity. The Plan denied your request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT codes S9129 and S9131 have a status indicator of "I" in the Physician Fee Schedule. This means that they 
are invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for 
coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay 
for the home physical and occupational therapy services provided on March 18, 2020 billed with codes S9129 
and S9131.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided and billed under codes
 98941, 99212, G0283, and 97110. 
 
You asked the Plan to pay for chiropractic services. You say that these services should be covered by the Plan. 
The Plan denied your request. The Plan says while a portion of these services were covered, codes G0283 and 
97110 are not covered by the Plan or by Medicare. 
 
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 service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided and billed under codes G0283, and 97110.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are most appropriate for acute rehabilitation 
post-hospital stay. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that 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 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 the 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
provider on June 15, 2020. 
 
You asked the Plan to waive the copayment for lab work. You say that you don't know why you are being 
charged twice for one visit. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient diagnostic tests/in-network/lab services.  
 
You have been asked to pay a $40 copayment for lab work. This copayment is for lab work, not an office visit; 
therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/in-
network/lab 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 lab work provided 
by a participating provider on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 15, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers 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 
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 a domiciliary, rest home visit provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. You say that you have had good results with this 
doctor and you are very comfortable with this doctor and do not want to go to another doctor. The Plan denied 
your request. The Plan says you must receive care from in-network providers with the exception of emergency 
or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an 
in-network provider, which requires prior authorization from the plan.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Farxiga tablets.  
 
Benefits for self-administered drug 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on July 1, 
2020 to July 2, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment should be 
waived because you and your wife were not told about these charges and because your wife could have 
transported you. 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 $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for the ambulance services. This copayment applies regardless 
of the reason for the transport. 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 ambulance services you 
received on July 1, 2020 to July 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ALS non-emergency ambulance (A0426) ALS 
emergency ambulance (A0427) and ground mileage (A0425) provided. 
 
You asked the Plan to pay for the ambulance service. You say that 2 checks from the plan were sent to you on 
10/27/19. One for $859.70 the other for $352.05. You were never told by the Plan that they were to go to the 
ambulance company The Plan denied your request. The Plan says the claim processed correctly. Two checks 
were sent to you for payment of the services and the checks were cashed on 11/05/2019. 
 
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 
$1211.75 20% coinsurance for ambulance services (emergency and non-emergency). for Ambulance services.  
 
You have been asked to pay $1211.75 for the ambulance services. The ambulance services fall within the 
Ambulance services benefit category. The plan had approved payment and two checks were sent to you for 
payment of the services and the checks were cashed on 11/05/2019. 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 pay for the 
ALS non-emergency ambulance (A0426) ALS emergency ambulance (A0427) and ground mileage (A0425) 
provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day services (99239) provided on 
November 20, 2019. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
reconsideration because the diagnosis code is not for hospice. The Plan denied your request. The Plan says the 
member was enrolled in hospice on this date of service so the provider needs to bill Original Medicare. 
 
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 hospital discharge day services (99239) provided on 
November 20, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forthe eye surgery provided on March 4, 2020.You asked the Plan to pay forthe eye surgery. You say that you were told the procedurewas covered.The Plan denied your request. The Plan says that the in network facility has to waive the charges.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the eye surgery by a contract provider. The file does not show that the Planprovided notice that the eye surgery would not be covered. Under Medicare rules, this means the eye surgery is considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe eye surgery provided on March 4, 2020.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/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.