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

We decided that the Plan does not have to pay for the chiropractic services received on August 17, 2020 to 
August 21, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you were not aware that you needed a 
referral. The Plan denied your request. The Plan says the services received are not a covered benefit when 
provided by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic services received on August 17, 
2020 to August 21, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided from February 14, 2020 to March 19, 2020. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you feel the enrollee should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says the enrollee received SNF care on the dates of service at issue in this appeal. The 
Plan says that the correct copayment has applied per the enrollee's contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $0 copayment per day for days 1-20 and a $160 copayment per day for days 21-100 for Skilled 
nursing facility (SNF) care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received SNF 
care for 22 days from November 26, 2019 to December 9, 2019 and from December 15, 2019 to December 24, 
2019. The enrollee had been asked to pay a $0 copayment for days 1-20 and a $160 copayment per day for 
days 21 and 22. The file shows the enrollee then received SNF care for 34 days from February 14, 2020 to 
March 19, 2020 and was asked to pay a $160 copayment per day for days 23-56, totaling $5440. However, the 
file shows the enrollee reached her out of pocket maximum with the claim for dates of service March 1, 2020 to 
March 19, 2020, reducing the total cost share to $5214.36. The SNF care falls within the Skilled nursing 
facility (SNF) care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
skilled nursing facility (SNF) care provided from February 14, 2020 to March 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four (TOF) testing with CPT code 95999 
provided on June 16, 2020. 
 
You asked the Plan to pay for CPT code 95999. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 95999 is Unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train 
of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is 
inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. 
There is no separate code for train of four monitoring. Based on this information, we decided that Medicare 
rules for coverage of CPT code 95999 have not been met. Therefore, we decided that the Plan does not have to 
pay for the train of four (TOF) testing with CPT code 95999 provided on June 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 11, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 
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 on March 11, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
You asked the Plan to pre-approve the SNF care. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require 
skilled nursing or therapy services on a daily basis and 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drug injection provided on April 
16, 2020. 
 
You asked the Plan to waive the cost share for the Part B drug injection. You say that you are appealing this 
charge. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $196 deductible that applies towards Medicare Part B drugs and 20% 
coinsurance for Medicare Part B drugs, if not billed in conjunction with an office visit copayment.  
 
The Part B drug injection you asked the Plan to waive the cost share for falls within the 'Medicare Part B 
Prescription Drugs' benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $196 deductible that applies towards Medicare Part B drugs and 20% coinsurance for 
Medicare Part B drugs, if not billed in conjunction with an office visit copayment. The record shows you were 
not charged an office visit copayment on this date of service. See chart below. 
 
Date of Service Service Allowed Amount Deductible/Coinsurance Member 
Liability 
April 16, 2020 Part B drug injection $529.44 $196 $196 
 Part B drug injection $333.44 (This is 
the remaining 
allowed amount. 
($529.44 - $196) 
20% $66.69 
Total    $262.69 
This cost sharing is a contractual obligation that had not been met at the time the Part B drug injection was 
received on April 16, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the 
Part B drug injection provided on April 16, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the chest x-ray (71046) provided on February 8, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the documentation supports one unit of this service 
which has already been approved and paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence that this code has been 
previously approved and paid. It is the burden of the Medicare Health Plan to substantiate the denial with 
evidence. The denial is not substantiated, and we must find in your favor. 
 
 Therefore, we decided that the Plan has to pay for the chest x-ray (71046) provided on February 8, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections (J0178) provided August 14, 
2020 to September 18, 2020. 
 
You asked the Plan to waive the coinsurance for the injections. You say that only a specialist visit copayment 
should be applied. The Plan denied your request. The Plan says the correct coinsurance should be 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B 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 (J0178) provided 
August 14, 2020 to September 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the kidney imaging services with CPT code 78707 provided 
on June 23, 2020. 
 
You asked the Plan to pay for CPT code 78707. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  for Medicare to consider coverage and payment 
for any item or service, the  information submitted by the supplier or provider must confirm that Medicare  
coverage criteria have been met. 
  
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that 
two separate kidney imaging services were provided on June 23, 2020. The file shows that the Plan paid for 
one kidney imaging service (1 unit of 78707-26) provided on June 23, 2020. Therefore, we decided that the 
Plan does not have to pay for the kidney imaging services with CPT code 78707 provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided from November 6, 2019, to July 22, 
2020. 
 
You asked the Plan to pay for the medical services. You say that the Plan is incorrect as you are able to bill 
Fee-for-Service Medicare for services. The Plan denied your request. The Plan says that the billing provider 
was not active with Medicare on the date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial rationale is that this provider is not Medicare-enrolled/active 
with Medicare on these dates of service. The Plan neglected to include in the case file any evidence to support 
this assertion. Review of the Medicare database shows this provider as enrolled. Without any direct evidence 
that the provider is not eligible to receive Medicare payment, we find this denial is unsubstantiated. Therefore, 
we decided that the Plan has to pay for the medical services provided from November 6, 2019, to July 22, 
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 the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says non-emergent services rendered by non-
participating providers in 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 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 medical services provided by 
an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the inpatient hospital care provided 
was medically necessary. The Plan denied your request. The Plan says the 
readmission was for a continuation or recurrence of the reason for the 
initial admission. The Plan says that the readmission was 
preventable. 
 
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 pay for the inpatient hospital care. Our physician 
reviewer found the enrollee is with a past medical history of diabetes, chronic kidney disease, chronic 
obstructive pulmonary disease and congestive heart failure who was treated in the acute hospital 
or an exacerbation of his chronic obstructive pulmonary disease and congestive 
heart failure. He re-presented to the hospital with shortness of breath, weight gain and 
weakness and was re-admitted and treated again  for chronic obstructive pulmonary 
disease and congestive heart failure. 
 
Based on the medical records provided there is documentation that the readmission was medically necessary.  
Based on the medical records provided the readmission appeared to be for the same chronic 
obstructive pulmonary disease and congestive heart failure exacerbation as the first hospitalization and appears 
to be the result of a premature discharge from the prior hospital stay. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion services provided on May 16, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the infusion services. You say that the enrollee met the standard for management 
and the determination should be reversed. The Plan denied your request. The Plan says you did not request 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 infusion services provided on May 16, 2020 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 16, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 16, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
May 30, 2020, to June 3, 2020, and June 20, 2020, to June 28, 2020. 
 
You asked the Plan to pay for SNF services provided from May 30, 2020, to June 3, 2020, and June 20, 2020, 
to June 28, 2020. You say that the services which the enrollee required and received are coverable under the 
Medicare Act. The Plan denied your request. The Plan says the enrollee did not received any skilled nursing or 
therapy services during this time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF services provided from May 30, 
2020, to June 3, 2020, and June 20, 2020, to June 28, 2020. Our reviewer says that daily skilled services are not 
necessary. Our physician reviewer found enrollee did not have daily skilled nursing needs that required the 
specialized skill, knowledge and judgment of a skilled professional nurse. The reviewer found that the enrollee 
did not have daily skilled nursing needs that required the specialized skill, knowledge and judgment of a skilled 
professional therapist. The reviewer found that the enrollee did not require daily skilled nursing and/or skilled 
therapy on 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 services provided from May 30, 2020, to June 3, 2020, and June 20, 2020, 
to June 28, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for the skilled 
nursing facility (SNF) services provided from May 30, 2020, to June 3, 2020, and June 20, 2020, to June 28, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services rendered from July 31, 2020, to 
August 21, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to twelve sessions per ninety-day period, and no more 
than twenty sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that you did not receive acupuncture 
for the treatment of chronic low back pain. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services rendered from July 31, 2020, to August 21, 2020.