Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for weakness and falls and was treated for pneumonia and a urinary tract infection. Medical 
conditions are stable. There are medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric scooter. 
 
You asked the Plan to pre-approve the electric scooter. You say that the records provided support the need for a 
motorized scooter. The Plan denied your request. The Plan says the records do not show that the enrollee is 
wheelchair bound, unable to operate a manual wheelchair, or in a home that is wheelchair accessible. The Plan 
says that a request for a power wheelchair is not reasonable and necessary at this time. 
 
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 electric scooter. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the documentation does not 
reveal that the enrollee has a personal mobility deficit that impairs participation in MRADLs in the home. The 
documentation does not reveal why the enrollee's mobility deficit is unable to be helped by a walker, cane, or 
manual wheelchair. There is no objective gait or neuromuscular exam. The documentation is not clear that the 
enrollee can safely maneuver the requested scooter in the home or that the requested scooter will significantly 
improve activities of daily living performance in the home. Our physician reviewer found that the requested 
electric scooter is not medically necessary based on the documentation provided. 
 
 
 
 
 
 
 
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 electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electric scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 8, 2020. 
 
You asked the Plan to pay for chiropractic services other than manual manipulation of the spine. You say that 
this care should be covered by the Plan. The Plan denied your request. The Plan says you received chiropractic 
care on July 8, 2020. Billing code 98941(billed with GA modifier)- Spinal physical or manipulative treatment 
performed for Maintenance Care rather than restorative care is not a Medicare covered service. The provider 
submitted information to show you were made aware of this prior to the service being given and you signed an 
ABN (Advance Beneficiary Notice of Noncoverage).  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. Maintenance care is not covered. The records show 
that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not 
have to pay for chiropractic services provided on July 8, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided on October 1, 2018. 
 
You asked the Plan to pay for the skilled nursing services. You say that the enrollee's stay at the skilled nursing 
facility was medically necessary. The Plan denied your request. The Plan says Medicare denies a claim if it is 
not received by the Plan within 12 months or 1 calendar year from the date when the services were rendered. 
The Plan also says that this claim was received on June 26, 2020, and the time limit for filing has expired. 
 
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 the skilled nursing services was not filed until October 1, 2018. 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 skilled nursing services provided on October 1, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 16, 2020, by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that these medically necessary services 
were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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 16, 2020, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 4, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the nursing facility service (99309). You say that the service was medically 
necessary and provided in good faith. The Plan denied your request. The Plan says you did not request 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 service 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 the service. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on August 4, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 27, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these 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 outpatient services provided on January 27, 2020, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a 3 minute phone call 
and you disagree with what the doctor told you. 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 $30 
copayment for each specialist visit.  
 
You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctors office visits 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 a specialist visit provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve the nerve block. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 nerve block. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered investigational and not 
medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  
degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment 
following knee replacement; or as a treatment for individuals who are not candidates for knee replacement 
surgery. 
 
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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for post stabilization care provided to the enrollee from June 2, 2020 to 
June 4, 2020. 
 
You asked the Plan to pay for post stabilization care. You say that this care was medically necessary for this 
critically ill enrollee. The Plan denied your request. The Plan says that the enrollee did not have prior 
authorization. 
 
The Plan must follow Medicare rules. The rules say that the treating physician decides when the enrollee is 
stable for transfer or discharge. This physician's decision is binding on the health plan. 
 
In this case, the treating physician documented that the enrollee was not stable for transfer at or near the time of 
admission. It should be noted that the enrollee passed on June 5, 2020, based on the information provided by 
the Plan. Medicare coverage criteria for post stabilization were met. Therefore, we decided that the Plan has to 
pay for post stabilization care provided to the enrollee from June 2, 2020 to June 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 
18, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that a new doctor must have 
called the ambulance but it was not an emergency. 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 $100 
copayment for ambulance services.  
 
You have been asked to pay a $100 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 ambulance services 
provided on September 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider from May 6, 2019, to June 14, 2019. 
 
You asked the Plan to pay for the 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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
from May 6, 2019, to June 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for an endoscopy received. 
 
You asked the Plan to adjust the copayment for the procedure. You say that this should be a $275 copayment 
for a free-standing facility. The Plan denied your request. The Plan says the copayment 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 $325 
copayment for outpatient surgery.  
 
You have been asked to pay a $325 copayment for the procedure. the procedure falls within the outpatient 
surgery benefit category, as the services were provided in an outpatient hospital. The $275 copayment is for 
services received in an ambulatory surgical center. 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 adjust the copayment for 
an endoscopy received.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for nerve conduction studies (95910) and 
needle electromyography (95886) provided on May 16, 2019. 
 
You asked the Plan to waive the coinsurance for nerve conduction studies and needle electromyography. You 
say that you were not told you would have to pay for these services. The Plan denied your request. The Plan 
says these services processed 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 Medicare-covered diagnostic procedures and tests.  
 
You have been asked to pay a 20% coinsurance for nerve conduction studies and needle electromyography. 
Nerve conduction studies and needle electromyography falls within the Medicare-covered diagnostic 
procedures and 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 coinsurance for nerve conduction 
studies (95910) and needle electromyography (95886) provided on May 16, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on July 22, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were admitted to the hospital 
so should not owe a 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 a $90 
copayment for emergency care.  
 
The medical records show that you were not admitted inpatient after receiving emergency care on July 22, 
2020. Therefore, you are responsible to pay the $90 copayment.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided on July 
22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital observation services coded G0378 provided on 
 
You asked the Plan to pay for the hospital observation 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 payable. 
 
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 G0378 is hospital observation service, per hour. 
 
We find that CPT code G0378 is not supported in the medical record. Specifically, edited to OCE edit 57 
billing denial as not meeting all requirements to receive a comprehensive APC payment. Based on this 
information, we decided that Medicare rules for coverage of the hospital observation services have not been 
met. Therefore, we decided that the Plan does not have to pay for the hospital observation services coded 
G0378 provided on
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 20, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on April 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 22, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says these 
services were not referred by a network provider, urgent, emergent or 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 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 22, 2020 by 
an out of network (OON) provider.