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

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider from May 9, 2020, to May 12, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this should all be 
considered a continuous stay. 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 $275 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient mental health 
care/in-network.  
 
You have been asked to pay a $275 copayment per day for days 1-3 for an inpatient hospital stay. The total 
amount you are being asked to pay is $825 (4275 x 3 days = $825). An inpatient hospital stay falls within the 
inpatient mental health care/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 waive the copayment 
for an inpatient hospital stay provided by a participating provider from May 9, 2020, to May 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 20, 2020, to April 
30, 2020. 
 
You asked the Plan to pay for home health services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is not participating with Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. 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. Medicare rules 
say that in order to receive payment for covered items or services, a provider must be enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. This provider is not enrolled in the Medicare program and is also out-
of-network with the Plan. Therefore, this provider is not eligible for payment by the Plan for home health 
services. Based on this information, we decided that Medicare rules for coverage of home health services have 
not been met. Therefore, we decided that the Plan does not have to pay for home health services provided from 
April 20, 2020, to April 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a PET scan (78815) received on July 21, 
2020. 
 
You asked the Plan to waive the copayment for a PET scan. You say that you were repeatedly informed by the 
provider that the copayment would be $10. 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 $250 
copayment for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $250 copayment for a PET scan. A PET scan falls within the "Outpatient 
diagnostic tests and therapeutic services and 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 
copayment for a PET scan (78815) received on July 21, 2020.  
 
Your complaint about receiving inaccurate or misleading information about cost-sharing from the provider 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 the services provided on March 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice. 
 
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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the services provided on March 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) and ground 
mileage (A0425) provided on December 5, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for non-emergent ambulance transport and ground mileage. You say that the 
services rendered were medically necessary. The Plan denied your request. The Plan says prior authorization 
must be obtained for non-emergent services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) 
and ground mileage (A0425) provided on December 5, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on June 4, 2020. 
 
You asked the Plan to waive the coinsurance for a nebulizer. You say that you do not agree with this 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 10% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 10% coinsurance of the allowed amount for a nebulizer. The total allowed 
amount is $48.21. The total amount you are being asked to pay is $4.83 ($48.21 x 10% = $4.83). A nebulizer 
falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on June 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 9, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can consider repeat RFA treatments upon completion of the rolling year on 
or after 12/20/20. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this request exceeds the utilization guideline of the LCD and is not eligible until 12/20/20. The enrollee 
had a right L3-4-5 RFA on December 20, 2019. There is also documentation of left L3-4-5 RFA on 5/29/20.  
Therefore, at this point, the request is considered medically unreasonable and unnecessary. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the closed treatment of metatarsal fracture services coded 
28475 provided on October 22, 2019. 
 
You asked the Plan to pay for the closed treatment of metatarsal fracture 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. 
 
In this case, the CPT Code Manual definition of code 28475 is closed treatment of metatarsal fracture; with 
manipulation, each. 
 
We find that CPT code 28475 is not supported in the medical record. Specifically, the submitted medical 
records do not include sufficient detail to support that closed treatment of etatarsal fracture; with manipulation 
was performed. Based on this information, we decided that Medicare rules for coverage of the closed treatment 
of metatarsal fracture services have not been met. Therefore, we decided that the Plan does not have to pay for 
the closed treatment of metatarsal fracture services coded 28475 provided on October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the enrollee has no acute symptoms that 
require 24 hour inpatient care. 
 
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 pre-approve inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee. This patient is not shown to be a danger to herself or others. The enrollee is not showing any auditory 
or visual hallucinations and is cooperative/compliant with treatment while not showing any threats the safety. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient 
psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
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 this is medically necessary. The Plan denied 
your request. The Plan says there is no need for continued skilled therapy services, continued care for complex 
needs, complicated wound care, or antibiotics through the enrollee veins. 
 
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 there are no identifiable skilled nursing 
or skilled therapy needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve ablation procedure (64635). 
 
You asked the Plan to pre-approve the nerve ablation procedure. You say that the ablation procedure 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 nerve ablation procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is considered experimental/investigational due to the wide 
variation of effectiveness in the peer reviewed literature. 
 
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 nerve ablation procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a nerve ablation procedure (64635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on March 13, 2020. 
 
You asked the Plan to pay for the assistant services. You say that the surgical assistant was chosen by the 
operating surgeon. The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon, or 
surgical team are not covered for the procedure performed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered.  
 
In this case, you billed assistant surgery services for CPT code 15931. The Medicare Fee Schedule Database 
contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant 
surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare 
coverage criteria for the assistant services have not been met. Therefore, we decided that the Plan does not have 
to pay for the assistant surgeon services provided on March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral nutritional supplies provided from October 14, 2019, 
to November 12, 2019. 
 
You asked the Plan to pay for enteral nutrition supplies. You say that you are appealing with supporting 
documentation. The Plan denied your request. The Plan says the denial of payment for these supplies is correct, 
because the documentation submitted does not include valid proof of delivery for these supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine that payment is due for a claim.  
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery for the supplies billed on this claim. Namely, the documentation includes a packing list which does not 
confirm delivery of the supplies, and a delivery ticket which does not show receipt of the supplies by the 
enrollee. The Plan requested this documentation, but it was not provided. Without this information, you have 
not furnished sufficient information to justify payment of the claim as it has been billed. Based on this 
information, we decided that Medicare rules for coverage of enteral nutrition supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for enteral nutritional supplies provided from October 
14, 2019, to November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003) for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the notes provided do not show the current level of strength, range of motion or 
gait, nor do they contain an in-home evaluation showing adequate access or maneuverability space between 
rooms or how the member currently completes activities of daily living such as toileting, feeding, dressing, 
grooming and or bathing in the home. 
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that states why a standard wheelchair could not be used. The 
documentation does not show the current level of strength, range of motion or gait or ADL status, nor do they 
contain an in-home evaluation showing adequate access or maneuverability space between rooms or how she 
currently completes activities of daily living such as toileting, feeding, dressing, grooming and or bathing in the 
home. She lives alone. There is no documentation of any PT or OT evaluation either performed or even 
requested. In the absence of her functional status needs being identified, it is not possible to determine whether 
or not the enrollee needs a lightweight wheelchair or is it medically 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight wheelchair (K0003) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies and lumbar-sacral orthosis 
provided on March 26, 2020. 
 
You asked the Plan to pay for the electrical stimulator supplies and lumbar-sacral orthosis. 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. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies, or proof of delivery. 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 
electrical stimulator supplies and lumbar-sacral orthosis provided on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 21, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 must be billed with CPT code 
81479 for date of service May 21, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for Guardant360 testing provided on May 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a trial of a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the SCS trial. You say that the enrollee meets the Medicare criteria for this 
treatment due to his diagnoses of chronic pain syndrome and lumbar radiculopathy. The Plan denied your 
request. The Plan says the criteria for SCS are not met. 
 
The Plan follows Medicare rules. Medicare rules say that SCS may be covered as a late, if not last, resort 
treatment for chronic pain when certain other criteria are met.  
 
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 SCS trial. Our reviewer says that 
the requested treatment with SCS is not considered medically necessary. Our physician reviewer found the 
enrollee has chronic neck and low back pain. He has tried medication trials, facet blocks and other therapies. 
He had a Psychological evaluation; however, he does not have an evidence based indication for a SCS trial. 
Therefore, the request is considered not medically 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 SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a trial of a spinal cord stimulator (SCS).