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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from January 16, 2020 to January 25, 2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim 
must be submitted to Original Medicare first. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF) services provided to the enrollee from January 16, 2020 to January 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 19, 
2020. 
 
You asked the Plan to pay for the services. You say that these medical services are within the confines of 
prevailing medical practices and standards. The Plan denied your request. The Plan says payment to a hospital 
for laboratory tests furnished to an inpatient, whose stay is covered under Part A, is included in the PPS rate for 
PPS facilities or is made on a reasonable cost basis for non-PPS hospitals and is made at 101 percent of 
reasonable cost for CAHs. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Laboratory services provided while in inpatient are included in the payment to the facility. 
 
We find that the denied codes are not supported in the medical record. Specifically, payment for these 
laboratory codes are included in the payment to the inpatient facility. 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 laboratory services provided to the enrollee on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment defined by codes L3170, 
L0650, L3960, L3916, L1971 provided to the enrollee on March 20, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claims should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
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 to which support medical necessity for the supplies 
provided in this case. There is no itemized billing/shipping invoice. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the durable medical equipment defined by codes L3170, L0650, L3960, L3916, L1971 
provided to the enrollee on March 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services (A4221, A4222, J2260) provided 
from December 19, 2019 to December 25, 2019. 
 
You asked the Plan to pay for home infusion services. You say that this claim should be paid. The Plan denied 
your request. The Plan says these codes are 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. The provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We find that CPT codes A4221, A4222, and J2260 are not supported in the medical record. Specifically, no 
medical records have been submitted. Without this information, these codes cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of home infusion services have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion services (A4221, A4222, J2260) 
provided from December 19, 2019 to December 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment defined by codes L1971, L3170, 
L0650, L3960, L3916. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
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 to support medical necessity for the supplies provided in 
this case. There is no itemized shipping/billing invoice to verify the services billed. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for durable medical equipment defined by codes L1971, L3170, L0650, L3960, 
L3916.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient radiation therapy services provided on March 3, 
2020 to April 28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient radiation therapy 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. The Plan says that there are in-network providers available for 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 outpatient radiation therapy services provided on 
March 3, 2020 to April 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Taclonex. 
 
You asked the Plan to pre-approve Taclonex. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 pre-approve Taclonex.  
 
Benefits for Taclonex 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 20611) provided on February 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 20611 is ?Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting?. 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT code 20611 is not supported by the records provided. Our coding reviewer found that the medical 
records submitted do not include documentation of an "Arthrocentesis, aspiration and/or injection, major joint 
or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and 
reporting" being performed on February 13, 2020. The ultrasound images included are dated February 27, 2020 
which does not correspond to the date of service billed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 20611) provided on February 13, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 1, 2020 
to January 22, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the provider held you an extra day 
and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 $0 
copayment per day for days 1-20 and a $178 copayment per day for days 21-100 for SNF care.  
 
You had a SNF stay from January 1, 2020 to January 22, 2020. You are not being charged a copayment for 
days 1-20 (January 1, 2020 to January 20, 2020). You are responsible to pay a $178 copayment for day 22 
(January 21, 2020).  
 
You have been asked to pay a $178 copayment for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided from January 1, 2020 to 
January 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for immunotherapy injections (95115) 
received on May 14 and June 15, 2020. 
 
You asked the Plan to waive the coinsurance for immunotherapy injections. You say that you have not been 
charged coinsurance for these services before and believe the charge to have been applied in error. 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 Part B drugs and their administration.  
 
You have been asked to pay $2.16, or 20% of the Plan-allowed amount of $10.79, for each instance of 2 
immunotherapy injections. Immunotherapy injections fall within the "Medicare Part B prescription drugs" 
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 immunotherapy injections 
(95115) received on May 14 and June 15, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on August 7, 2019. 
 
You asked the Plan to pay for drug test. You say that you are appealing with records to support the code billed. 
The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the 
records do not include results for 8 to 14 drug classes. 
 
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 G0481 is drug test(s), definitive; qualitative or quantitative, all sources, includes specimen validity 
testing, per day; 8 to 14 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is supported in the medical record. Specifically, the documentation submitted 
supports that drug testing was performed on 8 to 14 drug classes, including metabolites. Based on this 
information, we decided that Medicare rules for coverage of drug test have been met. Therefore, we decided 
that the Plan has to pay for drug testing provided on August 7, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the provided is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The provider in question is not enrolled in the Medicare program. 
Payment cannot e made to a provider who is not enrollee in the Medicare program. 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 the services provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for rental of an oxygen concentrator (E1390) 
on July 20 and August 20, 2019. 
 
You asked the Plan to waive the coinsurance for rental of an oxygen concentrator. You say that you were 
charged cost-sharing on the rental of an oxygen concentrator even after you returned the item to the provider. 
The Plan denied your request. The Plan says the correct cost-sharing 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 durable medical equipment.  
 
You have been asked to pay $21.55, or 20% of the Plan-allowed amount of $107.75, per date of service for 
rental of an oxygen concentrator. An oxygen concentrator falls within the "Durable medical equipment (DME) 
and related supplies" 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 rental of an oxygen 
concentrator (E1390) on July 20 and August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider 
on June 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided by an out-of-network provider on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on March 11, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) rendered by the out of network (OON) provider on March 11, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stay at a SNF from March 1 to March 10, 
2020. 
 
You asked the Plan to waive the copayment for a stay at a SNF. You say that the Plan should be paying the 
facility bill based on the care you received. 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 $178 
copayment for days 21-100 of skilled nursing services within a benefit period.  
 
You have been asked to pay $1,424, or a $178 copayment for days 21-28, for a stay at a SNF. A stay at a SNF 
falls within the "Skilled nursing facility (SNF) 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 a stay at a SNF from March 1 to March 10, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided to the enrollee from December 27, 2018 
through January 20, 2019. 
 
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the stay is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided to the enrollee from December 27, 2018 through January 20, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network outpatient mental health services provided on 
February 6, 2020. 
 
You asked the Plan to pay for out of network outpatient mental health. You say that this service should be 
covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out 
of network care. 
 
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 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 these services. Therefore, we decided that the Plan 
does not have to pay for out of network outpatient mental health services provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that residents are not leaving the facility for outside 
provider appointments. The Plan denied your request. The Plan says the services were not urgent, emergent, or 
approved in advance. 
 
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 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 the medical services provided on April 3, 2020 by an out of network (OON) 
provider.