Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on February 13, 
2020 by an OON provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the treatment was provided 
pursuant to medical necessity/authorization or other specialty care policy or plan coverage benefits. The Plan 
denied your request. The Plan says the services were rendered by a non-participating 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 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 outpatient hospital services provided on 
February 13, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the spinal canal (72148). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is 
medically necessary. The Plan denied your request. The Plan says there is insufficient information to determine 
if criteria have been met 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that there is 
insufficient data to support performing an MRI. Our physician reviewer found the record does not include an 
indication for the MRI and is not deemed 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the spinal canal (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the skilled nursing facility (SNF) services 
provided from February 18, 2020, to March 16, 2020. 
 
You asked the Plan to waive the copay for the provided services. You say that the cost is a financial burden. 
The Plan denied your request. The Plan says per your plan, the copay applies. 
 
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 
copay per day for days 1-20, and a $0 copay for days 21-100 for skilled nursing facility (SNF) care.  
 
The file shows that you received 27 days of SNF care. You have been asked to pay a $20 copay per day for 
days 1-20. The services fall within the skilled nursing facility (SNF) care 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 copay for the skilled nursing facility (SNF) services provided from February 18, 
2020, to March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test(s) provided on June 2, 2020, by an OON 
provider. 
 
You asked the Plan to pay for the drug test(s). You say that you were not aware of the requirement of obtaining 
a prior authorization. You also say that the services were medically necessary, and provided in good faith. The 
Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan also 
says that the services were not 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 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 drug test(s) provided on June 2, 2020, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the services provided to the enrollee from 
April 22, 2020, to June 26, 2020. 
 
You asked the Plan to adjust the cost share. You say that the services used to be provided at a clinic, but it 
closed. The Plan denied your request. The Plan says the enrollee is responsible for the copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $200 copayment for outpatient hospital surgery services. The contract also says that enrollees must 
pay a $20 copayment for all other outpatient hospital services. 
 
Review of the file shows that the enrollee received outpatient surgery services on three occasions from April 
22, 2020, to June 26, 2020. Per the Plan contract, there is a $200 copayment for each of these services. 
However, the Medicare allowed amount for each visit was $56.88. As the allowed amount was less than the 
$200 copayment, the enrollee has been asked to pay the lesser amount for each visit. The enrollee also had an 
outpatient hospital visit on June 19, 2020. The enrollee has been asked to pay a $20 copayment for this visit. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to adjust the copayment for the services provided to the enrollee from April 
22, 2020, to June 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 19, 2020 by an 
out of network (OON) 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 an out-of-network 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 February 19, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on April 17, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says services should receive in network unless emergent or urgent. The 
member?s primary care physician did not refer for 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 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 outpatient office visit (99213) provided on 
April 17, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trimming of non-dystrophic nails and the office visit 
provided on November 18, 2019 by the out of network provider. 
 
You asked the Plan to pay for the physician services. You say that the services that were rendered to the 
enrollee were not related to hospice. The Plan denied your request. The Plan says the Medicare hospice benefit, 
through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of 
discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 
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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the trimming of non-dystrophic nails and the office visit 
provided on November 18, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on October 8, 2019 by an 
OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that a Plan representative assisted you over 
the phone in scheduling an appointment with an in network provider. You also say that once you arrived at the 
office, your insurance was verified, and all necessary authorizations were received. 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. The records show that you contacted customer service on October 8, 2019 requesting a 
primary care physician change. The Plan says that the representative assisted you in making an appointment 
with another provider on October 22, 2019. 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 outpatient office visit provided 
on October 8, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on March 9, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that this provider was in network when you 
enrolled with the insurance plan. You also say that you paid for this visit because you do not want to change 
providers. The Plan denied your request. The Plan says the service was rendered by a non-contracted 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 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 outpatient office visit provided on March 9, 
2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full inpatient acute rehabilitation 
criteria. The Plan denied your request. The Plan says the IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record does document 
a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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. The Plan denied your request. The Plan says transfer 
to a LTACH is not medically necessary at this time. 
 
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 as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level 
of care, there is no advantage in transferring the enrollee to the LTACH. Our reviewer found that the enrollee 
can remain at the current ACH until such time no acute services are required. Our physician reviewer also 
found that the enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram you received on June 22, 2020. 
 
You asked the Plan to pay for the mammogram. The Plan denied your request. The Plan says the benefit limit 
has been reached. 
 
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 $0 
copayment for one screening mammogram every 12 months.  
 
Review of the file shows that you had a screening mammogram on June 22, 2020. The records show that you 
also had a screening mammogram on February 28, 2020, which was paid by the Plan. The requested 
mammogram exceeds the benefit limit. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the mammogram 
you received on June 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not call for this service. 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 April 23, 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 April 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) received 
on May 2, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment was lower 
in the previous benefit year. 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 a $250 
copayment in 2020 for each ambulance trip. You had 1 ambulance trip. The Plan charged you $250 for these 
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 the ambulance services (A0427) received on 
May 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits (G0151). 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee's strength and mobility has 
drastically declined since the services stopped. The Plan denied your request. The Plan says the enrollee has 
had a total of 27 physical therapy visits with no improvement; enrollee is unable to stand, walk or talk. In the 
absence of progress, continuation of physical therapy does not meet criteria for approval. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
 
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 physical therapy visits. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the requested additional therapy 
is not generally accepted as specific and effective therapy for the patient's condition. The patient has had 
extensive therapy for this condition and is at a plateau. It does not appear that the patient requires the ongoing 
unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be 
safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient's 
caregiver is competent in a home exercise program and home safety. The specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the 
patient's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Specifically, additional physical 
therapy visits will not improve the enrollee's condition. Therefore, we decided that the Plan does not have to 
pre-approve additional physical therapy visits (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral hygiene instruction (D1330) provided June 11, 2020. 
 
You asked the Plan to pay for the oral hygiene instruction. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the service at issue is not covered under your dental plan. 
 
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 oral 
hygiene instruction (D1330) provided June 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on March 6, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 March 6, 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 by you on March 
6, 2020.