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

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided to the enrollee from March 2, 2020 to March 31, 2020.You asked the Plan to pay forthe SNF services. You say that these services were medically necessary.The Plan denied your request. The Plan says that the enrollee's condition no longer required daily skilled services at an inpatient SNF 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided to the enrollee from March 2, 2020 to March 31, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
10, 2019, to January 8, 2020. 
 
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied 
your request. The Plan says this was custodial 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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled 
nursing needs.  The enrollee did not have documented skilled therapy needs.  Daily skilled services were not 
required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The 
enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower level 
of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from December 10, 2019, to January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (88304, 88312) provided on March 
10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that You say that you want the claim considered 
under the Radiologist, Anesthesiologist, and Pathologists (RAPS) provision. The Plan denied your request. The 
Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been 
correctly denied. 
 
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 pathology services (88304, 88312) provided 
on March 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe services provided on February 27, 2020.You asked the Plan to pay forthe services. The Plan denied your request.The Plan says that the services were billed incorrectly.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to denycoverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan indicates that the services were billed incorrectly for reimbursement. However, the Plan does not provide details on what exactly was billed incorrectly. Without supporting documentation of the billing error, the Plan's denial cannot be substantiated.Therefore, we decided that the Plan has to pay forthe services provided on February 27, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy services provided from 
June 1, 2020, to June 30, 2020. 
 
You asked the Plan to waive the copayments for physical therapy. You say that the enrollee lives in the facility 
therefore there should not be any copayments. The Plan denied your request. The Plan says the enrollee is 
privately paying for the facility and was charged the copayments 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 $35 
copayment for physical therapy during a non-covered inpatient stay.  
 
The enrollee has been asked to pay a $35 copayment for each of the twelve days of physical therapy. The 
physical therapy falls within the non-covered inpatient stay benefit category. This means that the enrollee has 
been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayments for physical therapy services provided from June 1, 2020, to June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), extraction (D7210) 
and bone replacement graft (D7953) provided on January 7, 2020.  
 
You asked the Plan to pay for the guided tissue regeneration (D4266), extraction (D7210) and bone 
replacement graft (D7953). You say that in January 2020 you were in a plan that covered extractions. You say 
that the procedures performed are when you had coverage. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration (D4266), extraction (D7210) and bone replacement graft (D7953) provided on 
January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered from February 4, 2020 to 
February 7, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC of radiology services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The provider billed procedure codes 80053-26, 80197-26, 82550-26, 
83550-26, and 85025-26. These codes have a PC/TC indicator of 9 and the concept of a professional 
component does not apply and is not payable. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered from February 4, 2020 to February 7, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency department services provided on November 23, 2019. 
 
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says that the submitted documentation 
did not include an itemized billing statement. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department services have been met. Specifically, the record includes an itemized 
billing statement and proof of payment. Therefore, we decided that the Plan has to pay for emergency 
department services provided on November 23, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the negative pressure wound therapy services coded 97606 
provided on October 3, 2019. 
 
You asked the Plan to pay for the negative pressure wound therapy 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 97606 is negative pressure wound therapy (eg, vacuum 
assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), 
wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 
square centimeters. 
 
We find that CPT code 97606 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate the measurement of the total wound surface area for negative pressure wound therapy. 
Based on this information, we decided that Medicare rules for coverage of the negative pressure wound therapy 
services have not been met. Therefore, we decided that the Plan does not have to pay for the negative pressure 
wound therapy services coded 97606 provided on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure provided on May 14, 
2020. 
 
You asked the Plan to pay for the preventive procedure. You say that your provider is in-network with the Plan. 
The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive procedure provided on May 14, 2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for SNF services provided on October 1, 2019. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that this claim was not billed with a valid 
PDPM code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have been met. Specifically, per CMS, KAKE0 is a valid PDPM code as of 
October 1, 2019. Therefore, we decided that the Plan has to pay for SNF services provided on October 1, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an infusion pump placement (62362, 
E0783, 62350) provided May 12, 2020. 
 
You asked the Plan to waive the coinsurance for the infusion pump placement. You say that the copayment 
should be waived. The agent told you the service would be covered. 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 30% 
coinsurance for surgery performed at an out-of-network surgical center.  
 
You have been asked to pay a 30% coinsurance for the infusion pump placement. The infusion pump 
placement falls within the surgery performed at an out-of-network surgical center 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 an infusion pump placement (62362, E0783, 62350) provided May 
12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 5, 2020 by a non-
contracted provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-contracted provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 medical services provided on June 5, 2020 by 
a non-contracted provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the diagnostic contrast agent supplies you 
received during a PET scan on March 5, 2020. 
 
You asked the Plan to waive the cost sharing for the diagnostic contrast agent supplies. You say that you have 
had this procedure in the past with no 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 20% 
coinsurance for supplies used during outpatient diagnostic tests.  
 
Records show that you received a PET scan and a contrast agent (A9588) was used during this scan. You have 
been asked to pay 20% coinsurance for the diagnostic contrast agent supplies. the diagnostic contrast agent 
supplies falls within the supplies used during outpatient diagnostic tests 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 cost sharing for the diagnostic contrast agent supplies you received during a PET 
scan on March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation provided on 
February 8, 2020. 
 
You asked the Plan to pay for the non-emergent ambulance transportation. The Plan denied your request. The 
Plan says the services could have been provided in the network thru AMR. This was not an emergency/urgent 
transfer or a facility to facility transfer. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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. 
 
We looked at the file, Medicare rules and the Plan's rules. The file shows that the enrollee was transported 
from the emergency room to her private residence in stable condition. The file shows that 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 non-emergent ambulance 
transportation. We found no exception that would require the Plan pay for these services. Based on this 
information, we decided that Medicare rules for coverage of the non-emergent ambulance transportation have 
not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance 
transportation provided on February 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft provided on June 9, 2020. 
 
You asked the Plan to pay for the bone replacement graft. You say that you are requesting medical payment for 
the necessary bone graft. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on November 26, 2019. 
 
You asked the Plan to pay for the psychotherapy 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 
psychotherapy 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 psychotherapy services provided on November 26, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a receiver for use with a therapeutic continuous glucose 
monitor (CGM) and a supply allowance for a therapeutic CGM provided on January 31, 2020. 
 
You asked the Plan to pay for the CGM receiver and CGM supply allowance. You say that the Ox-code which 
was submitted under this claim is payable. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if any of the coverage criteria for CGMs are not 
met, the CGM related supplies will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The records show that the enrollee only takes one insulin injection 
per day. This means that the enrollee is not insulin-treated with multiple daily injections of insulin. There is no 
evidence that the enrollee is insulin-treated with a Medicare-covered CSII pump.  
 
 
Based on this information, we decided that Medicare rules for coverage of the CGM receiver and CGM supply 
allowance have not been met. Therefore, we decided that the Plan does not have to pay for a receiver for use 
with a therapeutic continuous glucose monitor (CGM) and a supply allowance for a therapeutic CGM provided 
on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient assisted living visit (99335) provided 
on April 10, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. 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 by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient assisted living visit (99335) 
provided on April 10, 2020, by an out of network (OON) provider.