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

 
We decided that the Plan does not have to pay for SNF services provided on March 28, 2020 through April 26, 
2020. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the SNF services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee's care needs at this point 
were custodial and, as a practical matter, could be provided at a lower level 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for SNF services provided on March 28, 2020 through April 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collagen dressing (A4452), Gauze (A6021), conforming 
bandage (A6402) and tape (A6646) provided on March 3, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this equipment was billed with a 
skilled nursing facility place of service code. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Specifically, this equipment was billed with 
place of service code 31 indicating that the member was in a Part A covered SNF stay. When DME is furnished 
for use in a SNF during a covered Part A stay, separate payment is not made. Therefore, we decided that the 
Plan does not have to pay for collagen dressing (A4452), Gauze (A6021), conforming bandage (A6402) and 
tape (A6646) provided on March 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not require the 
ambulance services. The Plan denied your request. The Plan says you were charged this cost sharing 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 $265 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $265 for these 
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 the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and 
injections (when block or injection is performed by a different physician or other qualified health care 
professional); prone position (CPT Code 01992) provided to the enrollee on May 11, 2020. 
 
You asked the Plan to pay for the monitored anesthesia care. You say that the monitored anesthesia should be 
subject to the same level of payment as general or regional anesthesia. The Plan denied your request. The Plan 
says local anesthesia or minimal conscious sedation may be appropriate. The Plan states the use of moderate 
sedation and MAC is usually unnecessary and documentation must clearly establish the need for such sedation 
in the specific patient. 
 
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 monitored anesthesia care. Our physician 
reviewer found the patient has no significant past medical history to warrant MAC. There is no documentation 
in the patient's record indicating that it is medically necessary to have an anesthesiologist present during a 
transforaminal epidural steroid injection (TFESI). Medical necessity for an anesthesiologist to administer MAC 
was not established. The review has determined that it is not medically necessary or reasonable for this enrollee 
to have MAC during the TFESI performed. Of note, MAC should be subject to the same level of payment as 
general anesthesia or regional anesthesia services.  However, in this case, MAC was not reasonable or 
necessary. 
 
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 monitored anesthesia care have not been met. Therefore, we decided that the 
Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (when block 
or injection is performed by a different physician or other qualified health care professional); prone position 
(CPT Code 01992) provided to the enrollee on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for professional services for allergen 
immunotherapy not including provision of allergenic extracts; 2 or more injections (CPT Code 95117) 
provided on March 30, 2020. 
 
You asked the Plan to waive the copayment for the specialist office services. You say that you were not 
charged a copayment for allergy shots prior to 2020. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC 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).  
 
Review of the file show that you received the specialist office services on March 30, 2020. The Medicare-
allowed amount for the specialist office services is less than the set $35 copayment; therefore, you have been 
asked to pay the lesser amount of $10.36 for the specialist office visit. Your EOC states that enrollees must pay 
a $35 copayment per visit to a specialist. 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 professional 
services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections (CPT 
Code 95117) provided on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided on May 28, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you sat in the emergency room for 
hours for a bed to be scrubbed and this should not have been an observation stay. The Plan denied your request. 
The Plan says the claim was processed accordingly with your 2020 EOC 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).  
 
Review of the file show that you received observation care, computed tomography (CT) scan and Medicare 
Part B drugs on May 28, 2020. You are asked to pay a $200 copayment for observation stay, a $150 copayment 
for the CT scan and a $6.36 coinsurance for Part B drugs. Your EOC states, "enrollees must pay a $200 
copayment for outpatient hospital observation services, 20% coinsurance for Part B drugs and a $150 
copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine and stress 
tests). Unless the provider has written an order to admit you as an inpatient to the hospital, you are an 
outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital 
overnight, you might still be considered an "outpatient". If you are not sure if you are an outpatient, you should 
ask the hospital staff." 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 services provided on May 28, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 5, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
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 CPT code. 
 
We find that the billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 4, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
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 CPT code. 
 
We find that the billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), implant removal 
(D6100) and bone replacement graft (D7953) provided on January 16, 2020. 
 
You asked the Plan to pay for the guided tissue regeneration (D4266), implant removal (D6100) and bone 
replacement graft (D7953). You say that you were offered $2,000 in coverage or 50% reimbursement. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration (D4266), implant removal (D6100) and bone replacement graft (D7953) provided on 
January 16, 2020.  
 
Your complaint about the premium compared to the amount of coverage 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 pay for home visit for the evaluation and management of an 
established patient. Typically, 25 minutes are spent face-to-face with the patient and/or family. (CPT Code 
99348) provided to the enrollee on July 10, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The medical records show the submitted services were performed by a licensed vocational nurse (LVN). The 
medical record is electronically signed by the LVN, and the non-participating physician who is billing the 
services signs the medical record via electronic DocuSign. There is no documentation that the doctor was 
present during the home visit. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for home visit for the 
evaluation and management of an established patient. Typically, 25 minutes are spent face-to-face with the 
patient and/or family. (CPT Code 99348) provided to the enrollee on July 10, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 17, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 15, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physician's intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on November 15, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided December 27, 
2019. 
 
You asked the Plan to pay for the emergency room visit. You say that the plan should pay for CPT code 99285 
instead of 99284. The Plan denied your request. The Plan says the records do not support CPT code 99285. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, the presenting problem(s) are of high severity and pose an immediate significant 
threat to life or physiologic function. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, documentation does not 
support Medical Decision Making of high complexity, or presenting problem(s) of high severity that pose an 
immediate significant threat to life or physiologic function. Therefore, CPT code 99284 is more appropriate 
based on the records provided. Based on this information, we decided that Medicare rules for coverage of the 
emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency room visit (99285) provided December 27, 2019.
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 
record show that the member did not have evidence of stroke, heart attack or other such issue. 
 
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 showed 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 5, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
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 CPT code. 
 
We find that the billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
December 27, 2019. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct copayment 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 a $395 
per day copayment for days 1-4 for inpatient hospital care.  
 
You have been asked to pay a $395 for one day of inpatient hospital care. 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 inpatient hospital care provided on December 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on February 28, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you had to go from your 
cardiologist to the hospital. You say that the doctor would not let you go without going in an ambulance. You 
say that the hospital is the next building over. The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for an ambulance trip. Since an ambulance trip was provided, 
the correct copayment has been applied. An ambulance trip falls within the ambulance 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 for an ambulance trip provided by a participating 
provider on February 28, 2020.