Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 8, 2020, 
to February 25, 2020. 
 
You asked the Plan to pay for the skilled nursing services. 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's 
condition no longer required daily skilled services at an inpatient 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 8, 2020, to February 25, 
2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe lab services provided from April 11, 2019 to May 20, 2020.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says that the claims were not filed by an independent laboratory.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 services provided by a contract provider. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe lab services provided from April 11, 2019 to May 20, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says admission to an IRF is not medically necessary. The Plan says that 
the enrollee's needs may be met at a different level of care. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of an ankle fracture after a fall. The enrollee's medical problems are stable and 
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. While the medical record does document a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids on May 20, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the hearing aids. You say that the provider was chosen because of the 
convenience of the location. The Plan denied your request. The Plan says the hearing aids are limited to 
Hearing Care Solutions. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide hearing aids. 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 
hearing aids on May 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis provided by a participating 
provider. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that you reached your out-of-pocket 
maximum already. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for services to treat kidney disease/in-network/outpatient.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for dialysis. The total allowed amount is 
$2,996. The total amount you are being asked to pay is $599.20 ($2996 x 20% = $599.20). Your maximum out-
of-pocket amount had not been met at the time of these services. Dialysis falls within the services to treat 
kidney disease/in-network/outpatient 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 
dialysis provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluorescein angiography services coded 92235 provided. 
 
You asked the Plan to pay for the fluorescein angiography services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 92235 is fluorescein angiography (includes multiframe 
imaging) with interpretation and report, unilateral or bilateral. 
 
We find that CPT code 92235 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of Fluorescein angiography (includes multiframe imaging) with interpretation 
and report, unilateral or bilateral. Based on this information, we decided that Medicare rules for coverage of the 
fluorescein angiography services have not been met. Therefore, we decided that the Plan does not have to pay 
for the fluorescein angiography services coded 92235 provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided by a participating 
provider on May 28, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that it is the providers fault that 
an incomplete specimen was collected form your biopsy. 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 $285 
copayment for outpatient surgery/in-network/outpatient hospital.  
 
You have been asked to pay a $285 copayment for an outpatient surgery. An outpatient surgery falls within the 
outpatient surgery/in-network/outpatient hospital 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 biopsy provided by a participating provider on May 28, 2020.  
 
We note your complaint about having an incomplete biopsy done. Your complaint is a grievance that must be 
answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on February 7, 2020 to 
February 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that you would like these services paid for. The 
Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that this provider 
does not accept Medicare. 
 
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 dermatology services provided on February 7, 
2020 to February 14, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation you received. 
 
You asked the Plan to pay for the transportation services. The Plan denied your request. The Plan says this is 
not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation you received.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by you on May 11, 2020.You asked the Plan to pay forthe 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 May 11, 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 forthe ambulance services provided by you on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist office visits provided by 
participating providers on June 15, 2020, to June 29, 2020. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you already met your out-
of-pocket maximum. 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 $30 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $30 copayment for each specialist office visits. The total amount you are being 
asked to pay is $60. Your out-of-pocket maximum had not been met at the time of these services; therefore, the 
correct copayment has been applied. Specialist office visits fall within the physician/practitioner services/in-
network/specialist 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 specialist office 
visits provided by participating providers on June 15, 2020, to June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99350) provided on July 25, 2020. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says the submitted code does not 
appropriately reflect the services provided. 
 
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 99350 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval 
history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a 
significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99350 is not supported in the record. Specifically, the record does not include any 
evidence that the physician was present in the member's home. Based on this information, we decided that 
 
 
Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the home visit (99350) provided on July 25, 2020.
Appeal type: Testing
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 diagnostic tests. You say that you thought these services had been approved. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and prior authorization was denied for these 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 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 provide by an out of network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #'s 8 and 9 and retainer 
crowns (D6740) for tooth #'s 7 and 10. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that the enrollee wants new front 
teeth. You also say that the enrollee has an existing bridge from tooth #'s 7 to 10, with open lingual margins, 
and no decay. The Plan denied your request. The Plan says the documents fail to demonstrate a specific 
medical condition that would preclude the use of a removable partial denture. 
 
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. The Plan covers the pontics 
and retainer crowns when the services are medically necessary and reasonable.  
 
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 pontics and retainer crowns. Our 
reviewer says that these services are not medically necessary. Our physician reviewer found the documentation 
provided did not meet the criteria for coverage for a replacement fixed bridge replacing teeth #'s 8 and 9 using 
teeth #'s 7 and 10 as abutment retainers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6245) for tooth #'s 8 and 9 and retainer crowns (D6740) for 
tooth #'s 7 and 10.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for 
psychotherapy visits. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested provider is out-of-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 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 
a referral to an out-of-network provider for psychotherapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator provided on April 26, 2020. 
 
You asked the Plan to pay for neuromuscular stimulator. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this 
item was ordered by telemedicine which is 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 a neuromuscular stimulator 
provided on April 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto tab 10mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication falls under Part D coverage, but the enrollee does not have a Part D 
pharmacy benefit. 
 
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 Xarelto tab 10mg for the 
enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the octreotide injection rendered on 
January 3, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that the drugs should be covered under 
Part D. The Plan denied your request. The Plan says the coinsurance 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 20% of 
the plan allowed amount for Medicare Part B-covered drugs.  
 
Review of the file shows that you received an octreotide injection on January 3, 2020. You have been asked to 
pay 20% of the plan allowed amount for these services. These services fall within the Medicare Part B-covered 
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 the octreotide injection 
rendered on January 3, 2020.