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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested 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 enrollee required contact guard assistance for activities of daily living and 
transfers. The enrollee required supervision for bed mobility. The enrollee required stand-by assistance with 
walking 300 feet. The documentation does not support that the enrollee requires an intensive therapy program 
with 3 hours a day and an interdisciplinary approach to rehab care. The enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an observation stay and an inpatient 
hospital stay provided from March 2, 2020, to March 10, 2020. 
 
You asked the Plan to waive the copayments for an observation stay and an inpatient hospital stay. You say 
that you disagree with the multiple copayment charges. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient hospital observation and inpatient hospital care. 
 
The medical records show that you had an observation stay from March 2, 2020, to March 4, 2020. Therefore, 
you are responsible to pay the $250 copayment.  
 
The medical records show that you had an inpatient hospital stay from March 4, 2020, to March 10, 2020. 
Therefore, you are responsible to pay the $250 copayment. 
 
The total amount you owe is: $500. 
 
You have been asked to pay the total copayment amount of $500 for an observation stay and an inpatient 
hospital stay. An observation stay falls within the outpatient hospital observation benefit category. An inpatient 
hospital stay falls within the inpatient hospital 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 
copayments for an observation stay and an inpatient hospital stay provided from March 2, 2020, to March 10, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration because the initial 
claim was submitted timely. The Plan denied your request. The Plan says timely filing for initial payment 
requests is 1 year from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the SNF services was not filed until June 4, 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 SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care visit provided on May 6, 2020. 
 
You asked the Plan to pay for the nursing facility care visit (99309). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the submitted taxonomy corresponds to Registered Nurse 
which is not recognized as payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate taxonomy code. 
 
Data.CMS.gov, Crosswalk Medicare Provider/ Supplier to Healthcare Provider Taxonomy does not show the 
taxonomy submitted, Nurse Practitioner, as eligible for Medicare payment. Based on this information, we 
decided that Medicare rules for coverage of the nursing facility visit (99309) have not been met. Therefore, we 
decided that the Plan does not have to pay for the nursing facility care visit provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services and coinsurance for 
injections provided by a participating provider. 
 
You asked the Plan waive the copayment for specialist services and coinsurance for injections. You say that 
you cannot afford these copayments. The Plan denied your request. The Plan says the correct copayment and 
coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for physician/practitioner services/specialist services and a 20% coinsurance for Medicare Part B 
prescription drugs.  
 
You have been asked to pay a $30 copayment for specialist services and a 20% coinsurance of the allowed 
amount for injections. The total allowed amount is $611. The amount you are being asked to pay for injections 
is $122.20 ($611 x 20% = $122.20). The total amount you are being asked to pay is $152.20 ($30 + $122.20 = 
$152.20). Specialist services falls within the physician/practitioner services/specialist services benefit category 
and injections falls within the Medicare Part B prescription drugs 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 specialist services and coinsurance for injections provided by a participating 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you were told 
that you would only owe an office visit copayment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance for Medicare Part B drugs. 
 
You received a Medicare Part B drug injection. The allowed amount is $1,160.28 and 10% of 
that is $116.03.   
 
You have been asked to pay the total coinsurance amount of $116.03 for a Medicare Part B drug injection. A 
Medicare Part B drug injection falls within the Prescription Drugs 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 a Medicare Part B drug injection provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) provided by an out-of-network provider on 
December 6, 2019. 
 
You asked the Plan to pay for the frames. You say that you would like reconsideration because the provider is 
associated with your Plan. The Plan denied your request. The Plan says you did not purchase these frames from 
a preferred provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $150 eyewear allowance every 2 years through a preferred provider. 
 
We looked at the file and the Plan's rules. The record indicates that you did not purchase these items from a 
preferred provider as listed in your Vision Provider Directory. Based on this information, we decided that the 
 
 
Plan's rules for coverage of the frames have not been met. Therefore, we decided that the Plan does not have to 
pay for frames (V2020) provided by an out-of-network provider on December 6, 2019.
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 currently meets full IRF criteria based 
on her current condition and functional deficits. You say that her physicians have determined she requires 
intensive inpatient rehabilitation. The Plan denied your request. The Plan says care can safely be received in 
other settings. 
 
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 that the documentation does not support a need for an intensive therapy program with 
an interdisciplinary approach to rehab care. Our reviewer says that the enrollee's rehab needs can be met in an 
alternate, less intense 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
The Plan says that the enrollee can get the therapy needed at a lower level of care. 
 
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 enrollee does not meet the CMS coverage criteria for an IRF admission based on 
lack of medical stability and inability to tolerate therapies due to fatigue. The enrollee has multiple problems, 
but mainly hypoxia and debility. The enrollee is not medically stable enough to endure IRF level of therapies. 
The documentation does not support that there is a need for an intensive therapy program with 3 hours a day 
and an interdisciplinary approach to rehab care. The enrollee's rehab needs can be met in an alternate, less 
intense setting once able to tolerate therapies. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
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 is at risk for falls and fractures. You say 
that skilled intensive therapy is required to maximize her physical gain and improve quality of life.  The Plan 
denied your request. The Plan says care can safely be received in other settings. 
 
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 that the documentation does not support a need for an intensive therapy program with 
an interdisciplinary approach to rehab care. Our reviewer says that the enrollee's rehab needs can be met in an 
alternate, less intense 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee has impaired balance and 
decreased strength. You say that the enrollee will benefit from SNF care to improve her functional status. The 
Plan denied your request. The Plan says the clinical records received do not support the need for SNF 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 pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and insulin. The enrollee had stable vital signs, clear lungs, and was treated for a UTI. The 
enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a 
supervision to contact guard level with functional mobility, including gait to 110 feet. The enrollee required 
varying assist with activities of daily living. There are no identifiable skilled nursing service needs. While there 
are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does 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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you cannot afford to 
pay this. The Plan denied your request. The Plan says that the cost share 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 $275 
copayment for per day for days 1 through 6 of inpatient hospital care.  
 
You have been asked to pay a $275 copayment for the inpatient hospital care. The inpatient hospital care falls 
within the per day for days 1 through 6 of inpatient hospital 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 copayment for the inpatient hospital care provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided. 
 
You asked the Plan to waive the copayment for an EGD. You say that you cannot afford the charges. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for any surgical procedures during a colorectal screening and a $295 copayment for all other 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay a $295 copayment for an EGD. An EGD falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an EGD provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not feel like you 
should have to pay for this because you do not feel like you needed another angiography. The Plan denied your 
request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 
copayment for outpatient surgery/outpatient hospital facility.  
 
You have been asked to pay a $400 copayment for an outpatient surgery. The correct copayment has been 
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/outpatient 
hospital facility benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery 
provided by a participating provider.  
 
We note your complaint about feeling like a second test wasn?t necessary. Your complaint is a grievance that 
must be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses provided to the enrollee on April 10, 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 documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies, or proof of delivery. 
 
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 the denied codes is: 
 
HCPCS L3960: 
 
Shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated, includes fitting and 
adjustment 
 
HCPCS L3916: 
 
Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft 
interface, straps, prefabricated, off-the-shelf. 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation in the case file does not support that the requested shoulder/arm orthosis and the wrist/hand 
orthosis were medically reasonable and necessary for the enrollee in this case. A physical examination of the 
shoulder and the wrist would reasonably be required to adequately assess whether the shoulder/arm and 
wrist/hand orthoses were medically necessary for the enrollee. The documentation does not support that the 
orthoses were medically reasonable and necessary for the enrollee in this case, as there is insufficient 
documentation of a credible physical examination of the shoulder and the wrist/hand. 
 
 
 
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 pay for orthoses provided to the enrollee on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
provided by a physician. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
We looked at the file and the Plan?s rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider of the acupuncture services is not a 
physician. Acupuncture services must be provided by a physician for coverage consideration. 
 
 
 
Therefore, we decided that the Plan does not have to pay for the acupuncture services provided.