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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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 you will be able to fully participate in and benefit from theintensive 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 decidedthat the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your severity of illness does not meet SNF level of care. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional four (4) physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional 4 PT visits. You say that the enrollee demonstrates 
improvement that shows the extra therapy days were beneficial. The Plan denied your request. The Plan says 
additional physical therapy does not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional 4 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the requested additional therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for 
this condition and it appears that she does not require the unique skills of a professional therapist to safely and 
effectively provide treatment beyond what was approved by the health plan. The services do not need to be 
safely and effectively performed only by a therapist or under the supervision of a therapist. The nursing staff 
should be able to perform a maintenance program for the enrollee and the specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the 
enrollee's current condition or to prevent or slow further deterioration beyond what was approved by the health 
plan. 
 
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 additional 4 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 4 PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on June 3, 
2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $25 
copayment for each specialist visit.  
 
You have been asked to pay a $25 copayment for the specialist office visit provided. 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 office visit (99213) provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 4, 2019 by an out of 
network provider. 
 
You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says you did not request authorization prior to providing out-of-network services. 
 
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 this service. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on June 4, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on March 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist 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. 
 
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 specialist services provided on March 4, 2020 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest computerized tomography (CT) 
scan you had on April 17, 2020. 
 
You asked the Plan to waive the copayment for the chest CT scan. You say that this was a follow-up from a 
lung cancer screening you had had earlier, so you don't believe a copayment should apply. The Plan denied 
your request. The Plan says this copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for CT scans.  
 
You have been asked to pay a $150 copayment for the chest CT scan. Records from this service indicate that 
this CT scan was performed due to a lung nodule found previously.  The records do not indicate that this 
follow-up CT scan was for screening purposes. 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 chest 
computerized tomography (CT) scan you had on April 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on December 18, 2019, through January 2, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that this 
provider was in-network. The Plan denied your request. The Plan says the correct copayment has been 
appealed. 
 
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 $320 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $320 copayment per day for days 1-5. There is a $0 copayment for additional 
days for an inpatient hospital stay. The total amount you are being asked to pay $1,600 ($320 x 5 days = 
$1,600). An inpatient hospital stay falls 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 an inpatient hospital stay provided by a participating provider on 
December 18, 2019, through January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient care provided from February 28, 2020, to March 6, 2020. 
 
 
You asked the Plan to pay for inpatient care. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the enrollee could have been treated at a lower level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
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 inpatient care. Our reviewer says that the 
hospitalization at issue was medically necessary and reasonable. Our physician reviewer found the enrollee was 
evaluated in the emergency department for altered mental status.  She was found to have tachycardia, 
hyperglycemia and an elevated lactate.  There was concern that the enrollee had sepsis and an unidentified 
infection, for which she was started on antibiotics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have been met. Therefore, we decided that the Plan has to pay for 
inpatient care provided from February 28, 2020, to March 6, 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 pay for the medical services provided on May 30, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that follow up visits do not require authorization. The 
Plan denied your request. The Plan says the provided services are available within the network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on May 30, 2019 by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the back brace you received on April 12, 
2020. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that you are being overcharged for 
this item, because you can buy this brace much cheaper online. The Plan denied your request. The Plan says 
you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the back brace. The allowed amount for this item is 
$1048.04, so 20% coinsurance is $209.61.  This means that you have been asked to pay the correct amount 
based on your contract with the Plan, even if there are online vendors who may have this item for a less 
expensive price. 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 the back brace you received on 
April 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the routine eyewear rendered on March 12, 2020. 
 
You asked the Plan to pay more for these services. You say that you should not have been charged. The Plan 
denied your request. The Plan says the claim was processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 once every 24 months for routine eyewear. 
 
We looked at the file and the Plan's rules. The file shows that the Plan reimbursed the full $150 allowance for 
these services. Further payment is not covered by Medicare or your supplemental benefit with the Plan. 
Therefore, we decided that the Plan does not have to pay more for the routine eyewear rendered on March 12, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 5, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan 
says coverage is limited to one test per specimen. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that the testing at issue was not billed according to Medicare billing guidance.  Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant360 testing provided on May 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for facet joint injections provided on 
November 1, 2019, and December 6, 2019. 
 
You asked the Plan to waive the copayments for facet joint injections. You say that you disagree with the 
charges because you thought that you would only owe one $395 copayment. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You received facet joint injections on November 1, 2019, and December 6, 2019. A facet joint injection is 
considered an outpatient surgical procedure. Therefore, you are responsible to pay a copayment per each 
service. The total amount you owe is: $395 (copayment) x 2 (facet joint injections) = $790.  
 
You have been asked to pay the total copayment amount of $790 for facet joint injections. Facet joint injections 
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 copayments for facet joint 
injections provided on November 1, 2019, and December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services provided from January 1, 
2020, to January 28, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the procedure 
code is not valid for Medicare purposes. 
 
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 S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment. 
 
We find that CPT code S9328 is not supported. Medicare uses another code for the reporting of, and payment 
for, these services. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the home infusion therapy services provided from 
January 1, 2020, to January 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Electrocardiogram, routine ECG with at least 12-leads; 
interpretation and report on provided May 20, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says payment for this service would be 
included in the part-A DRG payment to the facility. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary 
covered services to the beneficiary either directly or under arrangements made with outside providers. You 
provided services to the enrollee while in inpatient status in a facility. Payment for this service would have 
been included under the facility claim for the inpatient stay. Payment to you for this service is the responsibility 
of the facility or hospital. Therefore, the plan is not required to pay you separately for this claim. Therefore, we 
decided that the Plan does not have to pay for Electrocardiogram, routine ECG with at least 12-leads; 
interpretation and report on provided May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
core buildup, including any pins when required (D2950) provided on May 20, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and core buildup. You say that the 
root was found to be completely obliterated with calcification and a non-patent apex was discovered. You also 
say that the canal was cleaned, shaped and disinfected. The Plan denied your request. The Plan says the 
problem focused limited oral evaluation exceeds the frequency limitation in the benefit plan. The Plan also says 
that there is no evidence that a crown was placed with this procedure, and therefore the criteria for coverage has 
not been met. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on May 14, 2020 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. The Plan contract also says that core buildup, including any pins when 
required (D2950) is limited to one procedure per tooth every five plan years, and has to be performed together 
with a crown. The record does not show that a crown was provided on this date of service, and in turn, the core 
buildup is not covered. Therefore, we decided that the Plan does not have to pay for the problem focused 
limited oral evaluation (D0140) and core buildup, including any pins when required (D2950) provided on May 
20, 2020.