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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on February 22, 2020 through 
February 24, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the 
notes do not show a medical reason for inpatient admission. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably 
expected that medically necessary care would span more than 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 on February 22, 2020 through February 24, 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 assisted living services provided on March 16, 2020 to 
March 30, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for assisted living 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 
provider, member or the facility. 
 
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 assisted living services provided on March 16, 
2020 to March 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit for the evaluation and management of an 
established patient (99336). You say that the Plan should pay this claim. The Plan denied your request. The 
Plan says the services were non-emergent and prior authorization was not requested. 
 
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 January 8, 2020 
by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures (97110) provided on February 3, 
2020. 
 
You asked the Plan to pay for the therapeutic procedures. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We asked our coder 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 therapeutic procedures. Our reviewer says that CPT code 
97110 does not meet criteria for billing or reimbursement consideration. Our reviewer found the therapy report 
does not include the amount of time spent on each area, therefore the units billed cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapeutic procedures have not been met. Therefore, we decided that the 
Plan does not have to pay for therapeutic procedures (97110) provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an outpatient hospital visit provided on November 5, 
2019. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you were not told 
there would be a charge for the room. The Plan denied your request. The Plan says that the copayment you are 
being charged is correct. 
 
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 did not submit the 2019 Evidence of Coverage. This means that we 
cannot verify the amount you are being asked to pay is correct or justified by the Plan contract. It is the burden 
of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated in this case 
and we must find in your favor. Therefore, we decided that the Plan has to waive the copayment for an 
outpatient hospital visit provided on November 5, 2019.  
 
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 pay for the acute inpatient hospital care provided from January 24, 
2020 to January 26, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the enrollee could have been treated in observation. 
 
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 the initial work-up in the emergency department was negative except for a 
questionable are of hypodensity of the left frontal lobe which did not correlate with her left arm or hand 
weakness and lack of other symptoms. The National Institutes of Health stroke score was 0. There was no 
expectation for the patient to require at least a two-midnight stay for any testing or treatment which would have 
taken less time and could have been completed at a lower level of care based on the documentation provided. 
 
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 January 24, 2020 to January 26, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
January 14, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be held 
liable for these charges because your doctor was not available. The Plan denied your request. The Plan says the 
copayment you are being charged 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 $395 
copayment per day for days 1 through 5 for Medicare-covered hospital stays at an in-network hospital.  
 
You have been asked to pay a $395 copayment for your one day inpatient hospital stay. An inpatient hospital 
stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an inpatient hospital stay provided on January 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin B12 injections provided from October 30, 2019 
to November 15, 2019. 
 
You asked the Plan to pay for the Vitamin B12 injections. You say that these injections were medically 
necessary due to the results of your blood work. The Plan denied your request. The Plan says Vitamin B12 
injections are not listed as a covered benefit 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 the Vitamin B12 injections 
provided from October 30, 2019 to November 15, 2019.  
 
Benefits for the Vitamin B12 injections 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the application of a multi-layer compression system to the leg during an 
occupational therapy visit provided on February 25, 2020 billed with code 29581-GO. 
 
You asked the Plan to pay for the compression system application. You say that it is felt that an additional 
copayment is not appropriate as this compression wrapping is a part of the occupational therapy plan of care 
and is billed as such. The Plan denied your request. The Plan says that a specialist service copayment was 
correctly applied to code 29581. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a 
$40 copayment for Medicare-covered occupational therapy visits. 
 
The Plan says the enrollee must pay an additional $45 copayment for specialist services provided on this date 
of service. However, based on the contract, the enrollee cannot be asked to pay more than a $40 copayment for 
a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed 
as part of the occupational therapy plan of care. There is no language in the contract which would create a 
reasonable expectation that an additional copayment would be applied to a service provided during an 
occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this 
service as it appears this care would have been rendered by the same provider who performed the manual 
therapy. Therefore, we decided that the Plan has to pay for the application of a multi-layer compression system 
to the leg during an occupational therapy visit provided on February 25, 2020 billed with code 29581-GO.  
 
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 physician services provided on January 22, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you were unaware that you needed permission 
from your primary care physician. The Plan denied your request. The Plan says prior authorization was not 
obtained. The Plan says that the member's primary care physician did not refer 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 physician services provided on January 22, 2019 
by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charge for the occupational therapy (OT) visit provided on 
April 9, 2020. 
 
You asked the Plan to waive the charge for the OT visit. You say that this claim had a copayment that was 
assessed incorrectly. The Plan denied your request. The Plan says the $40 copayment was correctly applied to 
the OT visit. 
 
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 $40 
copayment for Medicare-covered occupational therapy visits.  
 
You have been asked to pay a $40 copayment for the OT visit. 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 charge for 
the occupational therapy (OT) visit provided on April 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the additional copayment applied to the application of a multi-layer compression system to the leg during an occupational therapy visit provided on February 18, 2020 billed with code 29581-GO.

You asked the Plan to waive the additional copayment applied to the compression system application. You say that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the occupational therapy plan of care and is billed as such. The Plan denied your request. The Plan says that a specialist service copayment was correctly applied to code 29581.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a $40 copayment for Medicare-covered occupational therapy visits.

The Plan says the enrollee must pay an additional $45 copayment for specialist services provided on this date of service. However, based on the contract, the enrollee cannot be asked to pay more than a $40 copayment for a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed as part of the occupational therapy plan of care. There is no language in the contract which would create a reasonable expectation that an additional copayment would be applied to a service provided during an occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this service as it appears this care would have been rendered by the same provider who performed the manual therapy. Therefore, we decided that the Plan has to waive the additional copayment applied to the application of a multi-layer compression system to the leg during an occupational therapy visit provided on February 18, 2020 billed with code 29581-GO.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve non-emergent ambulance transportation (A0425 and A0428). 
 
You asked the Plan to pre-approve non-emergent ambulance transportation. You say that the requested non-
emergent ambulance transport to take the enrollee to and from dialysis is medically necessary as the enrollee 
needs a bariatric stretcher. The Plan denied your request. The Plan says that the services are not covered. 
 
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. Ambulance services are only covered when the patient's clinical condition is 
such that other methods of transport are contraindicated. In this case, the appellant is requesting non-emergent 
transportation via an ambulance for the enrollee to get to and from dialysis. In order to determine if the 
enrollee's clinical condition is such that other methods of transport are contraindicated, medical records are 
needed for review. We sent a request to the Plan to provide Plan medical records documenting the enrollee's 
clinical condition with no response. The Plan only provided a letter of medical necessity and did not show that 
any attempt had been made to obtain medical records. Therefore, we decided that the Plan has to pre-approve 
non-emergent ambulance transportation (A0425 and A0428).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neromuscular stimulator and supplies (E0745 and A4595), 
lumbar-sacral orthosis (L0650), alcohol wipes (A4245) and knee orthosis (L1851) provided on March 26, 
2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because this durable medical equipment is medically necessary. The Plan denied your request. The Plan says 
the submitted documentation does not include an itemized shipping/billing invoice to verify the billed supplies 
and this claim has not been billed correctly. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record does not 
include an itemized billing/shipping invoice to verify the delivered supplies and the delivery ticket is for a 
different date of service than what was billed. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Additionally, the member's address is not eligible for Medicare 
telehealth payment. Therefore, we decided that the Plan does not have to pay for a neromuscular stimulator and 
supplies (E0745 and A4595), lumbar-sacral orthosis (L0650), alcohol wipes (A4245) and knee orthosis 
(L1851) provided on March 26, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a skin dressing/skin substitute.
 
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 medical necessity criteria was not met. 
 
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 Apligraf in this case is medically reasonable and necessary, because the type of a chronic non-healing 
wound the enrollee has is an indication for its use based on the community standard of care. 
 
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 skin dressing/skin substitute.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevator feature for a wheelchair (E2300). 
 
You asked the Plan to pre-approve the power seat elevator feature. You say that the seat elevation feature is 
medically necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair power seat elevation features are not 
a covered item.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power seat elevator feature have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevator feature for a wheelchair (E2300).