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

 
We decided that the Plan does not have to waive the $100 copayment charged for ambulance transport 
provided on May 14, 2020. 
 
You asked the Plan to waive this copayment. You say that you cannot afford this copayment. The Plan denied 
your request. The Plan says this copayment is a contractual obligation. 
 
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 $100 
copayment for ambulance transport.  
 
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 $100 copayment charged for ambulance transport provided on May 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided by an out of network (OON) 
provider. 
 
You asked the Plan to pay for psychotherapy. You say that the member was referred to you. The Plan denied 
your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-
of-network 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 psychotherapy provided by an out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nutritional supplements (CPT Code S9368 x183). 
 
You asked the Plan to pre-approve the nutritional supplements. You say that the services are necessary. The 
Plan denied your request. The Plan says the information sent in does not show that you are being tube fed. The 
Plan states the information sent in does not show you have intestinal problems that will affect the food 
absorption. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
This code is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage 
of the nutritional supplements have not been met. Therefore, we decided that the Plan does not have to pre-
approve nutritional supplements (CPT Code S9368 x183).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe holter monitor, ambulatory electrocardiographic monitoring (93225) providedAugust 11, 2020.You asked the Plan to waive the copayment forthe holter monitor. You say that the bill was $150 and $140 was paid. You had to pick up the monitor and deliver it back and still have to pay for the reading and monitor.The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $10 copayment for diagnostic lab services and diagnostic procedures and tests. You have been asked to pay $10 copayment for the holter monitor. The holter monitor falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe holter monitor, ambulatory electrocardiographic monitoring (93225) provided August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on May 6, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says that 
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 
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 outpatient hospital services provided on May 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular junction testing provided to the enrollee on 
February 25, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 95937-26 (1 Unit) remains not supported. 
 
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 95937 is "neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any one method." 
 
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 testing. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 
95937 (neuromuscular junction testing (repetitive stimulation, paired stimuli) each nerve, any one method) is 
used for Neuromuscular Junction Testing and should not be used for Train of Four (TOF) Monitoring. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for neuromuscular junction testing provided to the enrollee on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 20, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that NGS panels must be billed with procedure code 
81479. 
 
The file shows that the NGS panel was not billed with code 81479 but as a panel of codes. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services rendered on May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that NGS panels must be billed with procedure code 
81479. 
 
The file shows that the NGS panel was not billed with code 81479 but as a panel of codes. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 18, 2020 to 
February 26, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care provided 
from February 18, 2020 to February 26, 2020 was medically necessary. The Plan denied your request. The Plan 
says that the inpatient hospital care provided from February 18, 2020 to February 26, 2020 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 acute inpatient hospital care. Our reviewer 
says that the inpatient hospital care provided from February 18, 2020 to February 26, 2020 was medically 
necessary. Our physician reviewer found the review indicates that the enrollee presented to the emergency 
room on 2/18/2020 with hypertension and altered mental status. On evaluation blood pressure was 160/114. 
The evaluation revealed creatinine 2.11 and an abnormal urinalysis. CT of the head revealed no acute process, 
chest x-ray demonstrated an elevated left hemidiaphragm and the EKG was sinus rhythm with PVCs. He was 
treated with IV fluids, IV antibiotics (Vancomycin/Cefipime), IV Hydralazine and Metoprolol, and IV MSO4. 
He was admitted. He was continued on IV antibiotics. He developed SVT with elevated troponins. He 
continued with medical treatment and had an echocardiogram and a swallowing evaluation. He also required 
treatment for gout vs pseudogout of the left knee.  His condition stabilized and improved with medical therapy 
and he was considered medically stable for transfer back to the nursing facility on 2/26/2020. 
 
The review has determined that the record showed that at the time of inpatient admission the admitting 
 
 
physician reasonably expected that the enrollee'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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 18, 2020 to February 26, 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 office visit (99202), chiropractic manipulative treatment 
(98940) and radiologic examination (X-Ray) of spine (72040, 72100) provided on December 9, 2019 to 
December 13, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit, chiropractic manipulative treatment and X-Rays of spine. You say 
that the services rendered are medically necessary. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services rendered by an out-of-network 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 office visit (99202), chiropractic manipulative 
treatment (98940) and radiologic examination (X-Ray) of spine (72040, 72100) provided on December 9, 2019 
to December 13, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee still requires 
medical management in the acute care hospital at this time. The enrollee's functional level does not appear to be 
able to tolerate skilled therapy services in a SNF at this time. The enrollee currently does not require skilled 
nursing or skilled therapy services (or a combination of these services) on a "daily basis" only in a SNF. As a 
practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing 
facility setting at this time. 
 
 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transportation of portable x-ray equipment and personnel to home or nursing home services coded R0070 provided on June 9, 2020.You asked the Plan to pay forthe transportation of portable x-ray equipment and personnel to home or nursing home 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 payable.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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.We find that CPT code R0070 is not supported in the medical record. Specifically, this service has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the April 2020 National Physician Fee Schedule Relative Value File. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home services have not been met.Therefore, we decided that the Plan does not have to pay forthe transportation of portable x-ray equipment and personnel to home or nursing home services coded R0070 provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services provided on March 28, 2019, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the behavioral health 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 by the facility or the provider; therefore, payment has been correctly denied. 
 
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 behavioral health services provided on March 
28, 2019, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fordurable medical equipment provided to the enrollee on March 26, 2020.You asked the Plan to pay forthe services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.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 fordurable medical equipment provided to the enrollee on March 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay from February 10, 
2018 to February 28, 2018. 
 
You asked the Plan to pay for the SNF stay. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says the member's 100 day skilled nursing benefit is 
exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from January 12, 2018 
through August 21, 2018. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) stay from February 10, 2018 to February 28, 
2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services rendered 
from June 14, 2020 to June 15, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
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 a 20% 
coinsurance for each Medicare-covered hospital stay.  
 
Review of the file shows that you received inpatient hospital services from June 14, 2020 to June 15, 2020. 
You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-
covered hospital stay 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 
inpatient hospital services rendered from June 14, 2020 to June 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography; any age, sleep staging with 1-3 
additional parameters of sleep, attended by a technologist (CPT Code 95808). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical information provided does not meet these criteria. 
 
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 service. Our physician reviewer 
found in this case, the clinical documentation provided for review did not readily support that any of these 
requirements for coverage were met. Rather, you had a positive diagnosis of obstructive sleep apnea (OSA) 
(with a baseline Apnea Hypopnea Index (AHI) noted in the records). There was no indication of a substantial 
change in body weight that would suggest resolution of OSA. There was otherwise no new therapy initiated 
that needed evaluation. In as much, the requirements of the LCD for repeat testing would not have been 
satisfied. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended 
by a technologist (CPT Code 95808).