Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) correction of trichiasis; 
epilation, by forceps only (67820) provided on July 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you were led to believe that this provider 
took your insurance, which they told you twice. You had to pay a $64 copay on top of everything and you 
would like the plan to take care of this bill. The Plan denied your request. The Plan says enrollee's must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 outpatient office visit (99202) correction of 
trichiasis; epilation, by forceps only (67820) provided on July 17, 2020 by an out of network (OON) provider.
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 you need to be admitted for rehabilitation. The Plan 
denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT PNS System. 
 
You asked the Plan to pre-approve a SPRINT PNS System. You say that the requested SPRINT PNS System is 
medically necessary. The Plan denied your request. The Plan says the requested SPRINT PNS System 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 a SPRINT PNS System. Our reviewer 
says that the requested SPRINT PNS System is not medically necessary. Our physician reviewer found per 
Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), the requested SPRINT PNS System - 
Suprascapular Nerve PNS Implant (C PT 64555, 76942) is not reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member. There is insufficient 
evidence in the literature and research to support the safety and effectiveness of PNS for the treatment of the 
enrollee's condition of chronic pain. Furthermore, the device appears to exceed the enrollee's need as she 
currently reports minimal pain on the 8/3/20 office visit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a SPRINT PNS System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT PNS System.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 8, 2020, 
to June 9, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically 
necessary. The Plan denied your request. The Plan says the overnight stay was done as outpatient and the 
enrollee was observed post-surgery as an outpatient. 
 
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 documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found a review of the medical records shows the procedure was performed without incident. 
There is no documentation which showed any necessity for the overnight stay to be reimbursed as an inpatient 
admission. There were no documented post-operative complications, the enrollee was hemodynamically stable, 
afebrile and did not have uncontrolled pain or other medical reasons for an admission. 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 acute inpatient hospital care provided from June 8, 2020, to June 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excess mileage for services provided on June 7, 2020. 
 
You asked the Plan to pay for the excess mileage charge (A0888). You say that the Plan should pay this 
mileage charge. The Plan denied your request. The Plan says you requested transportation beyond the closest 
hospital so the excess mileage is non-covered. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
We looked at the file and Medicare rules. The record shows you were transported to a facility of your choice 
which was not the closest appropriate facility. Based on this information, we decided that Medicare rules for 
coverage of the excess mileage charge (A0888) have not been met. Therefore, we decided that the Plan does 
not have to pay for the excess mileage for services provided on June 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift. 
 
You asked the Plan to pay for a stair lift. You say that you are unable to walk on stairs. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on May 
15, 2019. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you feel this 
copayment should have been waived. The Plan denied your request. The Plan says the claim has been 
processed correctly per your plan benefits. 
 
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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls 
within the emergency 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 the 
emergency room visit provided on May 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the transportation services provided. 
 
You asked the Plan to reimburse you for the transportation services. You say that this was the only way to 
safely transport. 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 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 reimburse you for the transportation services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says an incorrect provider type was entered. A corrected claim is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, an incorrect provider 
taxonomy was submitted on the claim. Based on this information, we decided that Medicare rules for coverage 
of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office 
visit (99214) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pay for a stair lift provided on August 2, 2019. 
 
You asked the Plan pay for a stair lift. You say that this is medically necessary. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have pay for a stair lift provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $50 copayment charged for urgent care provided on May 
30, 2020. 
 
You asked the Plan to waive this copayment. You say that you felt you had Covid 19 and could not get into 
your regular doctor's office. The Plan denied your request. The Plan says this copayment was charged based on 
the services provided and the Plan contract agreement. 
 
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 $50 
copayment for urgent care services. 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 $50 copayment charged for urgent care 
provided on May 30, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Duplex Scan (93971). 
 
You asked the Plan to pre-approve the Duplex Scan. You say that the scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Duplex scans are covered when 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 Duplex Scan. Our reviewer says 
that the requested scan is not medically necessary. Our physician reviewer found in the absence of new 
symptoms the imaging study is not indicated this far after the corrective procedure. 
 
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 Duplex Scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Duplex Scan (93971).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for back surgery (63047, 63048) performed 
on June 23, 2020. 
 
You asked the Plan to waive the coinsurance for back surgery. You say that you received the wrong benefit 
information when calling customer service. The Plan denied your request. The Plan says the correct 
coinsurance was 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 20% 
coinsurance for Medicare-covered visit for outpatient surgery.  
 
You have been asked to pay $1,316.62, or 20% of the Plan-allowed amount of $6,583.12, for back surgery 
performed on an outpatient basis. Back surgery performed on an outpatient basis falls within the "Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit 
category. Outpatient benefits are distinct from inpatient benefits. 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 back surgery (63047, 63048) performed on June 23, 2020.  
 
Your complaint about receiving erroneous or ambiguous information from a representative of the Plan 
regarding your cost-sharing responsibilities is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the 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 pre-approve an epidural injection. 
 
You asked the Plan to pre-approve epidural injection. You say that you were injured in a fall and are in a lot of 
pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
the documentation submitted does not include current pain issues, whether this request is diagnostic or 
therapeutic, current patient education, or current subjective and objective response from you regarding pain 
provocative maneuvers documented in pre-procedural measurements. 
 
The Plan follows Medicare rules. Medicare rules say that epidural injections may be covered for certain 
indications when 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 epidural injection. Our reviewer says 
that you do not meet the Medicare criteria for the requested epidural. Our physician reviewer found you need 
an updated history and physical examination before an interventional procedure. The most recent office note is 
more than 1 year ago. Therefore, this procedure is not medically reasonable or necessary 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 epidural injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an epidural injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from March 2, 2020 to 
March 8, 2020. 
 
You asked the Plan to pay for this claim. You say that the Plan should cover this cost. The Plan denied your 
request. The Plan says these drugs are not covered under Medicare Part B. 
 
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 pay for self-administered drugs provided 
from March 2, 2020 to March 8, 2020. Benefits for this claim may be available under Medicare Part D. Contact 
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve LDCT scan for lung cancer screening (CPT Code G0297). 
 
You asked the Plan to pre-approve the LDCT scan. You say that the services are necessary. The Plan denied 
your request. The Plan says that the member does not meet criteria 1 or 2. The Plan states coverage of this 
procedure code cannot be approved. The Plan states the pulmonary nodule seen on the member's chest 
radiograph done August 17, 2020, should be compared to prior computed tomography (CT) scans. The Plan 
states if the prior scans and/or reports cannot be located, a routine CT of the chest (CPT code 71250) can be 
ordered for follow-up. 
 
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 CT scan. Our physician reviewer 
found the records support the need for a follow up CT scan based on prior scan and recommendation for repeat 
scan. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve LDCT scan for lung cancer screening (CPT Code G0297).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that the enrollee's condition could be worse if she 
does not get the help she needs in the SNF. The Plan denied your request. The Plan says the denial of 
authorization for SNF care is correct. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While 
the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
 
 
therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
Skilled Nursing Facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility services provided from March 28, 
2019, to March 31, 2019. 
 
You asked the Plan to pay for the services provided. You say that the initial claim was submitted well within 
the timely filing limit. The Plan denied your request. The Plan says a clean claim was received untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a valid claim for the services provided was not filed until June 4, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the skilled nursing facility services provided from March 28, 
2019, to March 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 13, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the new patient office visit (99204). You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says you did not request prior authorization and the services were 
available to the enrollee in 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 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 the service. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on March 13, 2020 by an out of network provider.