Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from April 12, 2020, to 
May 11, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from December 20, 
2019, to June 20, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from April 12, 2020, to May 11, 
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 6, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you had a severe case of 
COVID-19 and thought that all copayments related to COVID-19 were waived. 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 received ambulance services on April 6, 2020. Ambulance services are not included in the COVID-19 
waiver. Therefore, you are responsible to pay the $100 copayment.  
 
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 April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided to the enrollee on May 4, 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 this was 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. 
 
In this case, the CPT Code Manual definition of HCPCS code G2025 is "Payment for a telehealth distant site 
service furnished by a rural health clinic (rhc) or federally qualified health center (fqhc) only." 
 
We find that CPT code G2025 is not supported in the medical record. Specifically, this code needed to also be 
billed with additional codes G0466, G0467, G0468, G0469, G0470, or G2025 with modifier 95. 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 telehealth services provided to the enrollee on May 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on June 11, 2019. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 this claim cannot be paid as billed. Specifically, the documentation does not support that these 
services were overseen by a licensed PT, the PTA note was digitally signed by the PTA, and electronically co-
signed (DocuSign) by a physician. The services of a PTA cannot be provided incidental to a 
physician/appropriately licensed other practitioner as they are not specifically qualified as licensed physical 
therapists. The submitted code does not appropriately reflect the services provided by the PTA. Based on this 
information, we decided that Medicare rules for coverage of the physical therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on June 11, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member can remain in the current acute care location until 
such time no further acute level care is needed. 
 
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. The member 
requires telemetry monitoring, BIPAP, IV medications, frequent labs, doctors' visits and therapy, all of which 
can be safely done in the current acute care setting. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99308) provided August 10, 2020. 
 
You asked the Plan to pay for nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim did not include a valid primary diagnosis. 
 
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 99308 is not supported in the medical record. Specifically, the claim did not include a 
primary, first-listed or principal diagnosis. Based on this information, we decided that Medicare rules for 
coverage of nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay 
for nursing facility care (99308) provided August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2751) on tooth #21 provided on July 10, 2020. 
 
You asked the Plan to pay for the crown. You say that your last crown was cracked. The Plan denied your 
request. The Plan says this service exceeds the frequency limitation in your benefit 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, if a porcelain, porcelain fused to metal, 
or cast metal crown is less than five years old its replacement is not a covered dental service. The record shows 
that you received a crown on tooth #21 on October 15, 2019, which was less than 5 years old when the new one 
was completed on July 10, 2020. Therefore, we decided that the Plan does not have to pay for the crown 
(D2751) on tooth #21 provided on July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 
12, 2019. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says the 
documentation submitted did not include a valid physician order/lab requisition or medical records (signed by 
the ordering physician); therefore the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services must be provided with a valid order.  
 
The denied codes cannot be verified without a valid physician order. 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 drug testing services provided to the enrollee on December 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent transportation provided on September 10, 
2019, to September 10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for non-emergent transportation. You say that you would like this claim reprocessed 
ad approved for payment. The Plan denied your request. The Plan says 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 non-emergent transportation provided on 
September 10, 2019, to September 10, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 6, 2020, to July 
2, 2020. 
 
You asked the Plan to pay for the home health services. You say that this claim should be paid. The Plan 
denied your request. The Plan says this home health claim had missing required information. 
 
The Plan must follow Medicare rules. Medicare rules say that for services provided after January 1, 2020, 
under the Patient-Driven Payment Model, a case-mix adjusted payment for a 30-day period of care is made 
using one of 432 HHRGs, which are represented by HIPPS codes. The rules also state that HHAs must report a 
Q-code to document where home health services were provided. 
 
In this case, the reported HIPPS code is no longer valid for services provided on or after January 1, 2020. In 
addition, the claim does not have a Q-code reported to document the location in which the services were 
 
 
rendered. Due to these deficiencies, we find that the denial of payment is supported. Therefore, we decided that 
the Plan does not have to pay for the home health services provided from June 6, 2020, to July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for infusion therapy services provided from 
October 19, 2020, to October 25, 2020. 
 
You asked the Plan to waive the copayment for infusion therapy services. You say that you met your out-of-
pocket maximum at the end of June 2019. The Plan denied your request. The Plan says you had not met your 
maximum out of pocket, $4000, for 2019. You were charged the copayments 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 each Medicare covered Part B drug for Medicare Part B Prescription Drugs.  
 
You have been asked to pay a $50 copayment for each Medicare covered Part B drug for infusion therapy 
services. Infusion therapy services fall 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 infusion therapy services provided from October 19, 2020, 
to October 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0429, A0425) 
provided February 27, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the care you received was 
poor and the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 
was applied for this service. 
 
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 Ambulance Services.  
 
You have been asked to pay a $250 copayment for the ambulance services. The ambulance transport falls 
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 
an ambulance transport (A0429, A0425) provided February 27, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your appropriate therapy needs are not precluded in an alternate level of 
care such as skilled nursing facility. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous durable medical equipment (DME) (E1399) 
provided January 15, 2020 to April 15, 2020. 
 
You asked the Plan to pay for the miscellaneous DME. You say that the provider is billing you for the 
difference between the charge amount and member responsibility including a late fee and you request 
reconsideration. The Plan denied your request. The Plan says the claim was processed correctly per the plan 
benefits.  
 
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 enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for durable medical equipment (DME) and related supplies.  
 
The enrollee has been asked to pay $83.36 for the miscellaneous DME. A check in the amount of $333.48 was 
sent to you on July 15, 2020 and was cleared on July 28, 2020. The miscellaneous DME falls within the 
durable medical equipment (DME) and related supplies benefit category. 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 pay for miscellaneous durable medical equipment (DME) (E1399) provided January 15, 2020 to April 
15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment services coded 98941 
provided on January 30, 2020. 
 
You asked the Plan to pay for the chiropractic manipulative treatment services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 98941 is chiropractic manipulative treatment (CMT); 
spinal, 3-4 regions. 
 
We find that CPT code 98941 is not supported in the medical record. Specifically, this service was billed 
without the appropriate acute treatment (AT) modifier. Based on this information, we decided that Medicare 
rules for coverage of the chiropractic manipulative treatment services have not been met. Therefore, we 
decided that the Plan does not have to pay for the chiropractic manipulative treatment services coded 98941 
provided on January 30, 2020.
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 your wife cannot care you by herself. The Plan 
denied your request. The Plan says your rehab and skilled nursing needs are not complex. 
 
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 physician reviewer found 
that you are at a moderate assist level for sitting and standing up. The records note that you declined to self-
propel in a wheelchair and staying up in a chair. You do not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services with regular physician evaluation. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for the skilled nursing facility (SNF) services 
provided. 
 
You asked the Plan to waive the co payment for the SNF services. You say that you would like this claim 
reprocessed and the co payment waived. The Plan denied your request. The Plan says the co payment 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 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
co payment per day for days 1-20 and a $160 co payment per day for days 21-100 for skilled nursing facility 
care.  
 
You have been asked to pay a total cost share of $1900 which is less than the required co payment that would be 
required by the Plan. The services provided fall within the skilled nursing facility 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 co payment for the skilled nursing facility 
(SNF) services provided.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided 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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be 
able to currently perform, fifteen hours per week of rehabilitative services with regular physician evaluation. 
Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF 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.