Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient provided on June 1, 2020 by an OON provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that it is the responsibility of the 
facility to obtain proper pre-certification and pre-authorization. You also say that your doctors rely on the 
facility to obtain the proper permissions. The Plan denied your request. The Plan says the service was rendered 
by an OON provider. The Plan also says that prior authorization was 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 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 
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 domiciliary or rest home visit for the 
evaluation and management of an established patient provided on June 1, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
records do not show that the required multidisciplinary evaluation has been performed. 
 
The Plan must follow Medicare rules. Medicare rules say that spinal cord stimulators are only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. The medical records provided do not indicate that the enrollee has 
undergone careful screening, evaluation and diagnosis by a multidisciplinary team. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection rendered on August 6, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that Medicare has approved and paid 
for the medication in the past. The Plan denied your request. The Plan says the coinsurance was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for chemotherapy and all other drugs covered under Medicare Part B.  
 
Review of the file shows that you received an injection on August 6, 2020. You have been asked to pay a 20% 
coinsurance for these services. These services fall within the chemotherapy and all other drugs covered under 
Medicare Part B benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the injection 
rendered on August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 26, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 March 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the requested 
power operated vehicle is not medically necessary. The documentation does not support that the enrollee's 
mobility deficit is unable to be helped by a manual wheelchair maneuvered by staff. The documentation reveals 
the enrollee has limited judgement and insight, and therefore does not support the enrollee's ability to safely 
operate the requested item independently. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 5, 2019. 
 
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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until July 30, 2020. A valid Waiver of Liability 
(WOL) was not received until October 28, 2020. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 5, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
August 3, 2020, to August 21, 2020. 
 
You asked the Plan to pay for the SNF services provided from August 3, 2020, to August 21, 2020. You say 
that the services should be covered. The Plan denied your request. The Plan says the skilled nursing facility 
care was no longer necessary. 
 
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 from August 3, 2020, to 
August 21, 2020. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found 
that the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge and 
judgment of a skilled professional nurse. The reviewer found that the enrollee did not have daily skilled nursing 
needs that required the specialized skill, knowledge and judgment of a skilled professional therapist. The 
reviewer found that the enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis 
in a SNF setting. The reviewer also found that the enrollee did not meet the severity of illness or intensity of 
service criteria for an inpatient basis in a SNF 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 SNF services from August 3, 2020, to August 21, 2020 have not been met. 
Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services 
provided from August 3, 2020, to August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discharge day management services (99239) provided on 
January 7, 2020. 
 
You asked the Plan to pay for the discharge day management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not include a discharge note with a documented duration of time of 31 minutes or more. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the record. Specifically, the record does not indicate that 
more than 30 minutes of discharge day management services were rendered on the billed date of service. Based 
on this information, we decided that Medicare rules for coverage of the discharge day management services 
have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management 
services (99239) provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services (84154, 36415, 84153) 
provided September 10, 2020. 
 
You asked the Plan to waive the copayment for the lab services. 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 $40 
copayment for lab services.  
 
You have been asked to pay the Medicare allowable copayment of $39.78 for the lab services. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for lab services (84154, 36415, 84153) provided September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 3, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services 
were not authorized. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on August 20, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the physician services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the services were not referred by a network provider nor approved in 
advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the physician services provided on August 20, 2020 by an out of network 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, or home with home health services. 
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections and a specialist visit (64615, 
J0585, J0585) provided August 11, 2020. 
 
You asked the Plan to waive the copayment for the injections and a specialist visit. You say that the copayment 
should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 20% 
coinsurance for Part B Drugs and a $50 copayment for specialist visits.  
 
You have been asked to pay a 20% coinsurance for the injections (Part B  Drugs) and a $50 copayment for a 
specialist 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 copayment for injections and a specialist visit (64615, 
J0585, J0585) provided August 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional miles provided during an ambulance transport 
on September 7, 2020. 
 
You asked the Plan to pay for the additional miles provided during an ambulance transport. You say that you 
disagree with the plan's denial. The Plan denied your request. The Plan says the additional services received are 
non-covered. 
 
Medicare pays for ambulance services only to the nearest appropriate facility. The Plan follows the same rules.  
 
We looked at this physician's review, the file, and Medicare rules. Review of the file shows that you requested 
to be taken to a specific facility considered to be further away from the closest hospital to you. Medicare does 
not pay for these additional services. Based on this information, we decided that Medicare rules for coverage of 
the additional miles provided during an ambulance transport have not been met. Therefore, we decided that the 
Plan does not have to pay for the additional miles provided during an ambulance transport on September 7, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the infusion services provided on July 2, 
2020. 
 
You asked the Plan to waive the copayment for the infusion services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received infusion therapy services on the date of service at issue in this appeal. 
The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $360 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received infusion therapy 
services on July 2, 2020 in an Outpatient hospital setting. You have been asked to pay a $180.33 copayment for 
the infusion services, which is less than the contracted $360 copayment amount.  
 
 
 
 
 
The infusion services fall within the Outpatient Surgery and Other Medical 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 copayment for the infusion services provided on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four additional intraoral periapical x-rays provided on 
August 31, 2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you were not aware that 
you were limited to intraoral x-rays only once per calendar year. The Plan denied your request. The Plan says 
benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on August 31, 
2020, which was covered by the Plan, and your intraoral x-rays benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the four additional intraoral periapical x-rays provided on August 
31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (98941) provided on August 21, 
2020 to September 4, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says the services were non-emergent and there were 
network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic services (98941) provided on August 21, 2020 to September 4, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam with dental code D0150 
provided on September 2, 2020. 
 
You asked the Plan to pay for dental code D0150. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D0150 is covered once every three 
years. The Plan says that you received this service on October 24, 2019, which is less than three years ago. 
 
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. 
 
The Plan offers a dental benefit in excess of Medicare coverage. In this case, the file shows you received a 
comprehensive oral exam with dental code D0150 on September 2, 2020. The Plan contract clearly says that 
dental code D0150 is covered once every three years. You previously received this service on October 24, 
2019, which is less than three years ago. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral exam with dental code D0150 provided on September 2, 2020.