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

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 17, 2020 and 
billed under codes 81201, 81203, 81209, 81162, 81242 81272 and 81403. 
 
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 the place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in a home setting POS 12.  Also, the laboratory results submitted indicate the 
specimen was collected on March 17, 2020 and received by the lab on April 30, 2020; therefore, the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes.  
 
In this case, this claim cannot be paid due to an issue with the place of service code and the timeframe in which 
the specimen was collected and received by the lab. Medicare rules for coverage of this service have not been 
met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on 
March 17, 2020 and billed under codes 81201, 81203, 81209, 81162, 81242 81272 and 81403.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay forthe physical therapy services rendered on May 22, 2020.You asked the Plan to pay forthese services. You say that the services should be covered.The Plan denied your request. The Plan says that the allowed amount for therapy was reached.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 states that the allowed amount has been reached for therapy. While there is a Medicare therapy cap, the services may be allowed if medically necessary. The Plan has not provided any medical records to show that the services were not medically necessary and eligible for the therapy cap.Therefore, we decided that the Plan has to pay forthe physical therapy services rendered on May 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on June 30, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for OON home health services. You say that this should be covered. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 home health services provided on June 30, 
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 3, 2020, by an out-
of-network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 on March 3, 2020, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computerized ophthalmic diagnostic 
imaging (92134) and the eye exam (92014) provided on June 19, 2020. 
 
You asked the Plan to waive the copayment for these services. 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 services 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 $45 
copayment for in-network Medicare covered vision services provided at a specialist's office.  
 
You have been asked to pay a $45 copayment for the in-network Medicare covered vision services provided at 
a specialist's office. 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 computerized ophthalmic 
diagnostic imaging (92134) and the eye exam (92014) provided on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller upgrade, harness, electrical 
connection, and power seat elevation system 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 pre-approve the accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the expandable controller 
upgrade, harness, electrical connection, and power seat elevation system for the electric wheelchair are 
medically necessary. A seat elevator is non-covered. Based on the medical records provided the enrollee's right 
upper extremity strength and range of motion are adequate to control the power options using their own 
switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller upgrade, harness, electrical connection, and power seat elevation 
system
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided on December 16, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for a lab test. 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. The Plan says that 
the referring provider is also 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 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 lab tests provided on December 16, 2019 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation services you received 
on August 7, 2020. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you were lied to, 
so you don't think you should have to pay this copayment. 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 $350 
copayment for hospital observation services.  
 
You have been asked to pay a $350 copayment for the hospital observation services. This copayment applies 
regardless of the reason for your stay or your satisfaction with the stay. 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 hospital observation services you received on August 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, prolonged service in the 
inpatient or observation setting, initial nursing facility care, and nursing facility discharge day management 
provided from November 14, 2019, to November 22, 2019. 
 
You asked the Plan to pay for the subsequent nursing facility care, prolonged service in the inpatient or 
observation setting, initial nursing facility care, and nursing facility discharge day management. You say that 
Medicare reflects that hospice is revoked for these dates of service. The Plan denied your request. The Plan 
says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated 
to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 5, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
nursing facility care, prolonged service in the inpatient or observation setting, initial nursing facility care, and 
nursing facility discharge day management provided from November 14, 2019, to November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for antigen therapy services (95165) on June 
22, 2020. 
 
You asked the Plan to waive the copayment for antigen therapy services. You say that you should not be 
responsible for a copay. The Plan denied your request. The Plan says the copay is correct. 
 
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 each specialist visit for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay a $30 copayment for each specialist visit for antigen therapy services. This 
services falls within the physician/practitioner services, including doctor's office visits 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 antigen therapy services (95165) on June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you had at an outpatient 
hospital facility on January 31, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you have never had to pay a 
copayment for this before. The Plan denied your request. The Plan says in 2020, you have a copayment for lab 
work, so this copayment was charged 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 $15 
copayment for lab services completed at an outpatient hospital.  
 
You have been asked to pay a $15 copayment for the lab services. 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 services you had at an outpatient hospital facility on January 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by Mauston Area 
Ambulance Association, Inc. on July 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 July 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 by Mauston Area 
Ambulance Association, Inc. on July 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from May 27, 2020, 
through May 28, 2020. 
 
You asked the Plan to pay for this service. You say that the inpatient hospital care provided was medically 
necessary for the enrollee. The Plan denied your request. The Plan says the inpatient hospital care provided was 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the enrollee had a history of coronary artery disease, hypertension, 
hyperlipidemia, and diabetes. He presented to the emergency room on May 27, 2020 with complaints of 
intermittent chest pain and pressure that radiated down both arms. A twelve lead electrocardiogram (EKG) was 
completed and concerning for anterolateral wall ischemia. Initial troponin was abnormal and elevated at .206.  
 
 
 
He was started on IV heparin drip and admitted to the cardiac floor for acute monitoring on telemetry, trending 
of troponin and consideration for possible angioplasty versus continued medical management. His troponin 
level decreased and he remained chest pain free. An echocardiogram was obtained which revealed an ejection 
fraction of 50%. He was discharged home on May 28, 2020 with outpatient follow-up. The review has 
determined that the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided from May 27, 2020, through May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2392) for tooth # 31 provided on July 9, 2020. 
 
You asked the Plan to pay for the dental service. You say that you live on a below poverty level fixed disability 
income. You say that you cannot afford to pay for these services. The Plan denied your request. The Plan says 
1 filling per calendar year is covered. The Plan says that the frequency limit has been exceeded. 
 
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 and fillings are a covered service, the 
frequency limit of 1 per calendar year has been exceeded. The record shows that the plan paid for the filling for 
tooth # 30 that you received on the same date of service. Therefore, we decided that the Plan does not have to 
pay for the filling (D2392) for tooth # 31 provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transmitter; external, for use with interstitial continuous 
glucose monitoring system (CPT Code A9277) and sensor; invasive (e.g., subcutaneous), disposable, for use 
with interstitial continuous glucose monitoring system, one unit = 1 day supply (A9276). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. Non-therapeutic interstitial 
continuous glucose monitoring systems are considered precautionary and therefore non-covered under the 
Medicare Durable Medical Equipment (DME) benefit. Therefore, we decided that the Plan does not have to 
pre-approve transmitter; external, for use with interstitial continuous glucose monitoring system (CPT Code 
A9277) and sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose 
monitoring system, one unit = 1 day supply (A9276).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a panniculectomy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the local infection is managed. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a severely enlarged overhanging lower abdominal pannnus that is causing functional 
impairment that has failed reasonable conservative management. The photographs are supportive of the clinical 
scenario. From Medicare, Medicare does not pay for any items or services that are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member. Thus, as the large overhanging abdominal pannus is clearly causing chronic functional impairment 
that has failed reasonable conservative dermatologic management, the requested procedure of panniculectomy 
satisfies Medicare medically necessary criteria. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a panniculectomy for the enrollee.  
 
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.