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

 
We decided that the Plan does not have to waive the deductible for the specialty physician services rendered. 
 
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the deductible was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $198 combined deductible for covered Part B services from both in-
network and out-of-network providers.  
 
The item or service you asked the Plan to waive the deductible for falls within specialists office services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $198 
combined deductible for covered Part B services from both in-network and out-of-network providers. This cost 
sharing is a contractual obligation that had not been met at the time these services were received
. Therefore, we decided that the Plan does not have to waive the deductible for the specialty physician 
services rendered.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for Medicare coverage of IRF 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 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 inpatient rehabilitation facility (IRF) admission and 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 though the 
copayment would be a different amount. The Plan denied your request. The Plan says the copayment has 
applied correctly in this case. 
 
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 per day, days 1-6 for inpatient hospital care.  
 
You have been asked to pay a total cost share of $975 for the inpatient hospital care (3 days x $325 
copayment). The services provided fall 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 copayment for the inpatient hospital care provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that you need 24/7 care and are being released 
from the current facility. You also say that you cannot take care of yourself. The Plan denied your request. The 
Plan says the guidelines for coverage of SNF care have not been met. 
 
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 you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. 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 SNF 
services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency services provided on August 
10, 2020. 
 
You asked the Plan to waive the copayment for the emergency services. You say that the hospital sent you 
there, you didn't go under your own volition. The Plan denied your request. The Plan says you were charged 
this coinsurance 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 $50 
copayment for Emergency Care.  
 
You have been asked to pay a $50 copayment for the emergency services. The emergency services fall 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 the emergency 
services provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 19, 2020 and June 9, 
2020. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were not maintenance. The 
Plan denied your request. The Plan says the treatments provided were maintenance. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to 
pay for chiropractic services provided on May 19, 2020 and June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Norco tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Norco tablets.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 19, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
include definitive laboratory results for 22 or more drug classes to support this code. Based on this information, 
we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the drug testing coded G0483 provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for closed chest procedures services coded 
00520 provided on June 12, 2020. 
 
You asked the Plan to pay for the anesthesia for closed chest procedures. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 00520 is not supported in the medical record. Specifically, this code was billed with 
modifier QC (single channel monitoring). Modifier QC is more appropriately reported with single-channel 
electrocardiograms, or ECG, monitoring and not anesthesia services. Based on this information, we decided 
that Medicare rules for coverage of the anesthesia for closed chest procedures have not been met. Therefore, we 
decided that the Plan does not have to pay for the anesthesia for closed chest procedures services coded 00520 
provided on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Drive Lateral Rotation mattress with low air loss. 
 
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. 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 mattress. Our reviewer says that the 
requested mattress is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not reveal extenuating factors on a physical exam that indicates this brand 
specific item is needed over an alternative low air loss mattress. The requested brand is not proven to be more 
effective than an alternative low air loss mattress. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Drive Lateral Rotation mattress with low air loss.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator electronic shock unit provided 
from March 20, 2020 to June 20, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator electronic shock unit. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator electronic shock unit provided from March 20, 2020 to June 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
23, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were told that gas would be 
covered for your personal circumstances. The Plan denied your request. The Plan says one comprehensive oral 
evaluation is covered every three years. The Plan says that the frequency limit for this service 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, the frequency limit of one 
comprehensive oral evaluation is covered every three plan years has been exceeded. The record shows that the 
Plan paid for this service that you received on July 2, 2018. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150) provided on July 23, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that if the enrollee had to go home, she would get hurt 
due to weakness. The Plan denied your request. The Plan says the denial of authorization for SNF care is 
correct. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a Skilled Nursing Facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 4) and the gingival 
irrigation (D4921 x 4) provided on February 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were advised you needed a deep cleaning. 
You say that you have never had this work performed in the past. You also say that due to some other 
questionable billing, you hope the provider office is not submitting claims incorrectly. The Plan denied your 
request. The Plan says 1 scaling and root planing procedure every 2 years, per quadrant, is covered. The Plan 
says that the frequency limit for this service has been exceeded. The Plan also says that gingival irrigation is 
not listed as a covered service. 
 
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 frequency limit of 1 scaling and 
root planing procedure every 2 years, per quadrant, has been exceeded. The record shows that the Plan paid for 
this procedure that you received for 2 quadrants on July 19, 2019, and the other 2 quadrants on July 26, 2020. 
Additionally, the gingival irrigation is not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for the scaling and root planing (D4341 x 4) and the gingival irrigation (D4921 x 
4) provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for a semi-electric hospital bed with an out-of-
network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is not medically necessary to go out of network to get this bed. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for a semi-electric hospital bed with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of LTACH 
services. 
 
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 there are no services at the LTACH that are not already available and covered at the 
current facility. This request for LTACH services is not medically necessary at this time. Transfer may be 
considered soon when treatment has completed and when appropriate for 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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, home with home health and home physical therapy. 
 
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 available in an IRF. Specifically, you are 
not shown to require 15 hours per week of rehab services and regular physician evaluation. Your 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 admission to an inpatient rehabilitation facility (IRF).