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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would be better served with 
his clinical complexities in an LTACH setting and should be afforded the opportunity for meaningful recovery 
in the appropriate level off care. The Plan denied your request. The Plan says the enrollee does not meet all of 
the requirements based on Medicare guidelines. 
 
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. Our 
physician reviewer found that the enrollee was admitted to the current acute care hospital with respiratory 
failure and an unresponsive state. He required mechanical ventilation but later was extubated and placed on 
BiPAP and high flow oxygen. The was noted to have acute lacunar infarct, sepsis, and acute renal failure which 
were treated with hemodialysis and vasopressors. Recent notes state that the enrollee had worsening lung 
congestion and effusion on CXR. The enrollee requires stabilization with additional acute care hospital services 
that the enrollee can safely receive at the current setting, the enrollee does not require any services at the 
LTACH that are not already available at the current hospital. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary. Transfer may be considered when treatment has 
completed and the enrollee is more stable. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80048 and 85025) provided on May 6, 
2019. 
 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the 
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting POS 11. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills, the place where the 
sample was taken is shown. 
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the record does not include a valid 
physician order/lab requisition form and the place of service code billed does not reflect where the sample was 
taken. Therefore, we decided that the Plan does not have to pay for laboratory services (80048 and 85025) 
provided on May 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation and management service (99538) provided on 
May 21, 2020. 
 
You asked the Plan to pay for an evaluation and management service. You say that this was billed correctly. 
The Plan denied your request. The Plan says the documentation does not support this code. 
 
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 99538 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
We find that CPT code 99538 is not supported in the medical record. Specifically, this code is for services 
before or after direct patient care and is not appropriate for a telehealth visit. Based on this information, we 
decided that Medicare rules for coverage of an evaluation and management service have not been met. 
Therefore, we decided that the Plan does not have to pay for an evaluation and management service (99538) 
provided on May 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on June 5, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you checked in but never saw 
anyone. You say that you went to the ER at a different hospital so the bill should be off your records. The Plan 
denied your request. The Plan says the copayment 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 a $90 
copayment for emergency services in an emergency room. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you were triaged at the ER. 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 ER visit provided on June 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services and travel allowance services coded  
87086, 80053, 85025, and P9604 provided on May 28, 2019 to July 23, 2019. 
 
You asked the Plan to pay for the laboratory services and travel allowance services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
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 87086, 80053, 85025, and P9604 are not supported in the medical record. Specifically, 
the documentation does not include a laboratory order for the services provided. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services and travel allowance services have not been 
met. Therefore, we decided that the Plan does not have to pay for the laboratory services and travel allowance 
services coded  87086, 80053, 85025, and P9604 provided on May 28, 2019 to July 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Logisticare mileage. 
 
You asked the Plan to pre-approve additional Logisticare mileage. You say that you are requesting additional 
mileage to get to dialysis appointments. The Plan denied your request. The Plan says your request exceeds the 
mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The request exceeds 
the mileage limit. Your EOC states that each one-way trip must not exceed 50 miles and a trip is considered 
one way, a round trip is considered two trips. Therefore, we decided that the Plan does not have to pre-approve 
additional Logisticare mileage.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 29, 2020. 
 
You asked the Plan to pay for the laboratory 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 the laboratory services are not supported in the medical record. Specifically, these services should 
be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on May 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 20, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was not billed in accordance with CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the denied codes are not supported in the medical record. Specifically, the revenue code and type 
of bill code used on the claim were not correct. 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 May 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone density study provided on February 24, 2020. 
 
You asked the Plan to pay for the study. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the bone density 
study provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81455) provided on November 6, 2019. 
 
You asked the Plan to pay for genetic testing. You say that this test improves patient care. The Plan denied 
your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that chemosensitivity profile tumor panels, 
regardless of whether it is performed by IHC or chromogenic in-situ hybridization (CISH), is not reasonable 
and necessary and is not a Medicare covered service.  
 
We looked at the file and Medicare rules. The service at issue is not covered under Medicare rules. 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 genetic testing (81455) provided on November 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound provided on July 7, 2020. 
 
You asked the Plan to waive the deductible for an ultrasound. You say that you were not informed that you 
would owe a deductible. 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. Your 
contract with the Plan says that there is a $500 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received an ultrasound on July 7, 2020. The record shows that you had paid $0 toward the $500 deductible 
prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $138.34. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time an ultrasound was 
received on July 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an 
ultrasound provided on July 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for the services provided on March 12, 2020. 
 
You asked the Plan to waive the cost-share for the services. You say that due to the COVID-19 pandemic, and 
your pre-existing cancer, your doctor felt that discharging you, although late same evening, with follow up care 
by a home care nurse and physical therapist next day would be safer and more reasonable due to the unknown 
risks of this novel virus and potential contamination. The Plan denied your request. The Plan says the claim 
was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received surgical services and physical therapy on March 12, 2020. You are 
asked to pay 30% coinsurance for the surgical services and a $40 copayment for the physical therapy. Your 
EOC states, enrollees must pay 30% coinsurance for each surgical or observation room service you get at an 
outpatient hospital and a $40 copayment for each covered physical, occupational and speech therapy visit. 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 cost-share for the services provided on March 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services provided from July 16, 2020, 
through July 17, 2020, by an out-of-network provider. 
 
You asked the Plan to pre-approve the medical services. You say that the claim should be paid. The Plan 
denied your request. The Plan says there are multiple in-network providers within 30 miles of the members 
residence that could have rendered the 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services provided from July 16, 2020, through July 17, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on January 8, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services are 
not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. You received the services with the reasonable expectation that the services would be 
covered. Therefore, we decided that the Plan has to pay for the lab services provided on January 8, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 10, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory 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 laboratory services provided on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on August 20, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you have sensitive 
teeth, and were in pain. You also say the dentist was not able to help you, so you feel this service should be 
covered. The Plan denied your request. The Plan says you exceeded the frequency limits set in the subscriber 
agreement. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on August 13, 2020, and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (CPT Code 
E0745) provided on July 26, 2020. 
 
You asked the Plan to pay for the DME. You say that the service is medically necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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. You are known to the Health Plan as 
employing a Teladoc consult to obtain the medical necessity information for the durable medical equipment. 
 
 
The Plan states this provider conducts unsolicited outreach telephone calls to enrollees and enrollees are not 
initiating a request to be contacted by this provider. The Plan states a physical examination by the ordering 
physician is not completed and clinical information is obtained by the provider via telephone interview. The 
Plan states it is unknown if the telephonic interview is conducted by a physician or employee of this provider. 
The Plan states that some enrollees have indicated they never spoken to the ordering physician documented in 
the records and there are no documented attempts to contact this enrollee's local physician. Therefore, we 
decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (CPT Code 
E0745) provided on July 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech generating device provided on March 3, 2020. 
 
You asked the Plan to pay for the speech generating device (E2508). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies. 
 
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. There is no itemized 
shipping/billing invoice to indicate the specific supplies, or Proof of Delivery indicating the billed items were 
delivered. 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 speech generating device provided on 
March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on July 23, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. 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 
the referring provider is also out-of-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 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 lab work provided on July 23, 2020 by an out of 
network (OON) provider.