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

 
We decided that the Plan does not have to waive the co payment for ambulance services provided by a 
participating provider. 
 
You asked the Plan to waive the co payment for ambulance services. You say that you had to call an ambulance. 
The Plan denied your request. The Plan says the correct co payment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
co payment for ambulance services.  
 
You have been asked to pay a $125 co payment for ambulance services. The correct co payment has been 
applied to the services that were provided. Ambulance services fall 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 co payment for ambulance services provided by a participating 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for facet joint injections (64635, 64636) 
provided August 19, 2020. 
 
You asked the Plan to waive the copayment for the injections. 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 $225 
copayment for Outpatient Surgery & Procedures.  
 
You have been asked to pay a $225 copayment for the injections. The injections fall within the Outpatient 
Surgery & Procedures 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 facet joint 
injections (64635, 64636) provided August 19, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the two electrocardiogram (EKG) interpretations and reports provided 
on July 20, 2020. 
 
You asked the Plan to pay for the EKGs. You say that this is separately payable and was necessary to treat the 
enrollee. The Plan denied your request. The Plan says that two physicians of the same specialty in the same 
group are considered the same physician for all purposes. As such, the EKG interpretations done by the 
provider at issue are considered to be included in payment to the emergency room physician who saw the 
patient. 
 
The Plan must follow Medicare rules. Medicare rules say that payment cannot be made for a review of an EKG 
without a written report as a review of the EKG is included in payment for the emergency room visit.  
 
In this case, the Plan's denial rationale is not supported. Interpretation and report of the EKGs was not done by 
the same physician that provided the evaluation and management (EM) service. It is, therefore, not appropriate 
to consider payment for the EM service to include payment for the second physician's service. One physician 
treated the enrollee directly, and a second interpreted and reported on the two EKGs the enrollee had done. 
Therefore, we decided that the Plan has to pay for the two electrocardiogram (EKG) interpretations and reports 
provided on July 20, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says underlying medical conditions are stable. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from a 
rehabilitation therapy program provided in an IRF. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment forthe cystoscopy provided on September 1, 2020.You asked the Plan to adjust the copayment forthe surgical procedure on the bladder. You say that the copayment should be less for a diagnostic preventative test.The Plan denied your request. The Plan says you were charged the copayment 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 $275 copayment for outpatient surgery in network, at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $248.64copayment for the surgical procedure on the bladder. The copayment is less because the allowed amount for the procedure was less than the copayment. Medicare defines this procedure as surgical. The surgical procedure on the bladder falls within the outpatient surgery in network 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 adjust the copayment forthe cystoscopy provided on September 1, 2020
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D imaging rendering provided July 18, 2020. 
 
You asked the Plan to pay for the 3D rendering. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim was not billed correctly. 
 
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 76376 is 3D rendering with interpretation. 
 
We find that CPT code 76376 is not supported in the medical record. Specifically, this code was not billed in 
conjunction with a qualifying imaging CPT code. Based on this information, we decided that Medicare rules 
for coverage of the 3D rendering have not been met. Therefore, we decided that the Plan does not have to pay 
for 3D imaging rendering provided July 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special power wheelchair with two (2) or more power 
seat options (power tilt and power recline options). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The member has diagnosis of post-
polio syndrome and stroke, which qualify as neurological conditions for which a Group 3 power wheelchair 
base would be medically necessary. However, the member does not have medical need for the Multiple Power 
Options included with the requested K0861 group 3 power wheelchair with Multiple Power Options. To 
qualify for a group 3 power wheelchair with Multiple Power Options, there must be medical need for a 
ventilator or for two power options: power tilt and power recline. Member is not stated to be at high risk for 
development of pressure ulcer: member is specifically stated to be at "Low Risk" in the PT wheelchair 
evaluation. Member has no current or history of pressure ulcers. Member does not utilize intermittent 
catheterization for bladder management; member does not have documented increased tone or spasticity. 
Member has no current or prior history of pressure ulcer. Member is specifically stated to be at "Mild Risk" for 
skin breakdown, based on PT wheelchair evaluation that lists Braden Score of 17. Member's needs could be 
met with an appropriate skin protection cushion. The member does not utilize "intermittent catheterization for 
bladder management." The member does not document increased tone or spasticity. In fact, notes state that 
member has "hypotonicity." As the member does not have need for both power tilt and power recline, the 
request for K0861 Group 3 power wheelchair with Multiple Power Options is not reasonable and necessary. 
Per Medicare criteria, Group 3 power wheelchair with Multiple Power Options is reasonable and necessary 
when the member uses a ventilator mounted to the wheelchair or when the member meets coverage criteria for 
a power tilt and power recline seating system. Neither of these conditions applies to this member. Therefore, 
the request for K0861 Group 3 power wheelchair with Multiple Power Options is not reasonable and necessary.  
Therefore, we decided that the Plan does not have to pre-approve special power wheelchair with two (2) or 
more power seat options (power tilt and power recline options).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network practitioner services provided to the enrollee from April 1, 2020, to July 27, 2020.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee 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 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 out of network practitioner services provided to the enrollee from April 1, 2020, to July 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran EGD provided on August 11, 2020 and August 14, 2020.You asked the Plan to waive the copayment foran EGD. You say that you were told that you would only owe a $185 copayment.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 thePlan clearly says that you must pay a $285 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $285 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 foran EGD provided on August 11, 2020 and August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on June 8, 2020.You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 did not pre-approve the surgical pathology services.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 surgical pathology services provided on June 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe imaging services provided on September 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says prior authorization was required, but not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan hasto 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. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay forthe imaging services provided on September 10, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre approve a Myoelectric upper extremity orthotic device (L8702)

You asked the Plan to pre-approve the orthotic device. You say that the device is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the orthotic device. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the evidence base for the requested technology consists of a few small studies, and while initially the results are promising, additional studies with larger sample size are needed to determine the technology's effect on health outcomes.

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 orthotic device have notbeen met.Therefore, we decided that the Plan does not have to pre-approvea Myoelectric upper extremity orthotic device (L8702)
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea computed tomography (CT) scan of the abdomen and pelvis with contrast (74177).You asked the Plan to pre-approvethis service. You say that a CT scan of the abdomen and pelvis is medically necessary for the enrollee.The Plan denied your request. The Plan says that the requested serviceis not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 this service. Our reviewer says that a CT scan of the abdomen and pelvis is medically necessary. Our physician reviewer found that a CT scan will provide important information to decide the best means of intervention of this patient who may require a surgical procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have been met.Therefore, we decided that the Plan has to pre-approvea computed tomography (CT) scan of the abdomen and pelvis with contrast (74177).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a caseagain 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 practitioner services provided to the enrollee on March 9, 
2020 and billed under codes 69210-RT and 69210-LT. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the Medicare National Physician Fee Schedule Relative Value File assigns code 69210 a 
"2" bilateral indicator. This means that for Medicare payers, the relative value units assigned to 69210 are 
already based on the procedure being performed as a bilateral procedure. In contrast to CPT instructions, the 
Centers for Medicare & Medicaid Services (CMS) allows only one unit of 69210 to be billed when furnished 
bilaterally. Therefore, the denial of CPT 69210-LT and 69210-RT is administratively upheld.  
 
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, based on the Medicare billing 
guidelines the units billed exceeds those expected for this code and service. The Plan states a corrected claim 
would be reviewed. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
to the enrollee on March 9, 2020 and billed under codes 69210-RT and 69210-LT.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from July 16, 2020, through August 2, 2020. 
 
You asked the Plan to pay for the continued SNF care. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the enrollee did not meet Medicare 
criteria for coverage of the continued inpatient skilled nursing facility care provided. 
 
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 continued SNF care. Our reviewer says 
that continued inpatient skilled nursing facility care provided was not medically necessary. Our physician 
reviewer found that due to the change of condition with weight loss and the COVID 19 infection, the member 
required skilled rehabilitation services to improve function due to weakness and deconditioning. He was treated 
with IV fluids during the acute infection but this was discontinued as of July 4, 2020. As of July 16, 2020, the 
member did not require any skilled nursing or rehabilitation services on a daily basis. He was not expected to 
make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish 
a safe and effective maintenance program. As a practical matter, the member did not require any skilled 
services on an inpatient basis, at a SNF level of care as of July 16, 2020. He did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. The member received skilled care and 
improved; however, his function had plateaued by July 16, 2020 and he did not require any further inpatient 
skilled rehabilitation services. The member's function was at or near his prior level of function and he could be 
discharged to a lower level of care for further services. As of July 16, 2020, the member required custodial 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pay for the continued inpatient skilled nursing facility (SNF) care provided from July 16, 
2020, through August 2, 2020.