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

 
We decided that the Plan does not have to waive the coinsurance for the Part B drug infusion services rendered 
on February 4, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of 
the total cost for Medicare-covered Part B prescription drugs, including chemotherapy drugs.  
 
Review of the file shows that you received Part B drug infusion services on February 4, 2020. You have been 
asked to pay 20% of the total cost for these services. These services fall within the Medicare-covered Part B 
prescription drugs, including chemotherapy 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 the Part B drug infusion services rendered on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96374, Q0138) provided on February 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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. 
 
In this case, the CPT Code Manual definition of code 96374 is "Therapeutic, prophylactic, or diagnostic 
injection (specify substance or drug); intravenous push, single or initial substance/drug". The CPT Code 
Manual definition of code Q0138 is "Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg 
(non-esrd use)". 
 
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 codes 96374 and Q0138 is not supported by the records provided. Our coding reviewer found that the office 
visit note dated February 3, 2020, includes documentation for CPT 96374 and HCPCS Q0138 given at 1pm on 
February 4, 2020. Therefore, dates of service cannot not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (96374, Q0138) provided on February 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
6, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the service was 
unnecessary so you are not obligated to pay the copayment. 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 $225 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $225 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 provided on March 6, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Xiaflex injections you received on 
March 2, 2020. 
 
You asked the Plan to waive the coinsurance for the Xiaflex injections. You say that you thought you would 
only have a $40 office copayment. You say that no one disclosed that you would have to pay more for these 
medications. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The 
plan says that it has waived all other cost sharing except for the coinsurance applicable to the drugs you 
received on this date. 
 
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 Part B-covered drugs.  
 
You have been asked to pay 20% coinsurance for the Xiaflex injections. Xiaflex injections fall within the 
Medicare Part B-covered 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. 
 
Please note that this decision is limited to the March 2, 2020, date of service.  If you have questions about any 
other dates of service you may want to appeal, please contact your health plan directly. Therefore, we decided 
that the Plan does not have to waive the coinsurance for the Xiaflex injections you received on March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health services provided from April 
6, 2020, to April 23, 2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says inpatient care 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient care. Our reviewer says that the 
requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that it did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance 
including auditory or visual hallucinations. It did not appear that active treatment was taking place. It did not 
appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of 
diagnosis. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient behavioral health services provided from April 6, 2020, to April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, comprehensive 
periodontal evaluation, complete series of intraoral x-rays, and adjunctive pre-diagnostic test provided on 
November 6, 2019 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, comprehensive periodontal evaluation, 
complete series of intraoral x-rays, and adjunctive pre-diagnostic test. You say that when you made the 
appointment you were told that your dental insurance was sufficient, and you could use it. You also say that 
you do not recall receiving any of the services listed on the bill. The Plan denied your request. The Plan says 
these services were rendered by an OON provider. The Plan also says that services provided OON are not 
covered. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation, comprehensive periodontal evaluation, complete series of intraoral x-rays, and 
adjunctive pre-diagnostic test provided on November 6, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on November 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 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 to the enrollee by an out-of-network provider 
on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for eyeglasses (V2781, V2784, V2745, V2020) 
provided on May 28, 2020. 
 
You asked the Plan to pay the full cost for eyeglasses. You say that you cannot afford to pay this charge. The 
Plan denied your request. The Plan says this processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan offers $100 towards the purchase of eyeglasses. You are responsible for any amount over 
$100. 
 
 
We looked at the file and the Plan's rules. The total charge for the eyeglasses at issue was $458.00. You have 
been asked to pay $290.40, which is less than the $358.00 designated by the rules in the Plan contract. 
Therefore, we decided that the Plan does not have to pay the full cost for eyeglasses (V2781, V2784, V2745, 
V2020) provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services coded 95865, the 
continuous intraoperative neurophysiology monitoring services coded G0453, and the neuromuscular junction 
testing services coded 95937 provided on January 27, 2020. 
 
You asked the Plan to pay for the needle electromyography services, the continuous intraoperative 
neurophysiology monitoring services, and the neuromuscular junction testing services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 codes 95865, G0453, and 95937 are not supported in the medical record. Specifically, 
the documentation submitted did not include documentation of needle electromyography; larynx; therefore, 
code 95865 cannot be verified. The required primary service code (95865) is denied, therefore, code G0453 
cannot be reimbursed separately. Lastly, the documentation submitted does not support neuromuscular junction 
testing (repetitive stimulation, paired stimuli), each nerve, any one method was performed. The documentation 
indicates that train of four testing was performed, which does not meet guidelines for use of code 95937. 
Based on this information, we decided that Medicare rules for coverage of the needle electromyography 
services, the continuous intraoperative neurophysiology monitoring services, and the neuromuscular junction 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the needle 
electromyography services coded 95865, the continuous intraoperative neurophysiology monitoring services 
coded G0453, and the neuromuscular junction testing services coded 95937 provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 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 to the enrollee by an out-of-network provider 
on January 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member does not require complex medical needs or 
complex wound care needs. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The member 
is stable and can be transitioned to an alternative lower level of care. There are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from nursing care, regular 
physician rounding, and intense rehab to build up strength and endurance. The Plan denied your request. The 
Plan says it is not reasonable to expect the enrollee will be able to actively participate in or benefit from the 
intensity of services in an IRF. 
 
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 physician reviewer found 
that the enrollee is at a moderate assist level for standing up, and maximal assist for toilet transfers. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that the admission and stay is medically necessary. 
The Plan denied your request. The Plan says the care could be received at a lower level of care. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with  the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
have complex wound care or other ongoing SNF level skilled nursing needs. The enrollee's functional level 
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist  to safely and effectively provide medically necessary and reasonable treatment in a SNF. The 
enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a 
"daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an 
inpatient basis, in a skilled nursing facility setting. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission as a swing bed patient for SNF care. 
 
You asked the Plan to pre-approve admission as a swing bed patient for SNF care. You say that the requested 
admission as a swing bed patient for SNF care is medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for admission as a swing bed patient for SNF care. 
 
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 admission as a swing bed patient for 
SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the 
enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment in a SNF.  The enrollee does not have complex wound care or other ongoing SNF level SN need. The 
documentation does not support that the enrollee's functional level requires skilled therapy services with the 
specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically 
necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy 
services (or a combination of these services) on a daily basis in a SNF. As a practical matter, this enrollee does 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission as a swing bed patient for SNF care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve admission as a swing bed patient for SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared 
for in her current condition at a lower level of care. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care, and does not require transfer. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee was admitted to the acute care hospital with COVID-19, respiratory failure, 
and sepsis. LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that 
are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital 
care, and acute care services have not been denied. The enrollee is alternating between BiPAP and nasal 
cannula oxygen. The documentation does not support that the enrollee requires services at the LTACH that are 
not available at the acute care hospital where she is currently receiving care. The documentation does not 
support that an additional 25 days of hospitalization are reasonably expected for the enrollee. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.