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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee was admitted to 
the hospital on 10/18/20 with debility, lower extremity weakness, and urinary retention with UTI secondary to 
a Foley catheter. He is currently participating in physical therapy and occupational therapy with minimal to 
moderate assistance x2 with transfers and ambulation.  
 
The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation 
needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation does not support that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visits provided on June 19, 2020, and 
June 23, 2020 by an OON provider. 
 
You asked the Plan to pay for the outpatient office visits. You say that this provider says that they are in 
network, and so does the Plan's provider guide. The Plan denied your request. The Plan says these services 
were rendered by a non-network provider. The Plan also says the services were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visits provided on June 19, 
2020, and June 23, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the computed tomography scan of the 
abdomen and pelvis (74177), computed tomography scan of the thorax (71260), and the MRI of the brain 
(70553) provided on June 3, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $125 
copayment for each in-network Medicare-covered diagnostic imaging service.  
 
You have been asked to pay $373.13 for the in-network Medicare-covered diagnostic imaging services 
provided. This is the Plan allowed amount which is less than the combined individual applicable copayments 
for these services. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to adjust the copayment for the computed tomography scan 
of the abdomen and pelvis (74177), computed tomography scan of the thorax (71260), and the MRI of the brain 
(70553) provided on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided from March 10, 2020 
to May 10, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not payable. 
 
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 provided from March 10, 2020 to May 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a chiropractor from 
June 22, 2020 to June 29, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says physical therapy and related services other than manual manipulation are 
not covered when provided by a chiropractor. 
 
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. The records show that the service at issue is not 
related to manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for 
physical therapy services provided by a chiropractor from June 22, 2020 to June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown and core buildup provided on March 16, 
2020. 
 
You asked the Plan to pay more for the crown and core buildup. You say that the dentist wouldn't have 
suggested the crown if it was not beneficial. You say that payment should be approved. The Plan denied your 
request. The Plan says your annual maximum was met. 
 
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, you also have an annual maximum of 
$1,000. The Plan paid $1,000 toward your dental benefits received on March 9, 2020 and March 16, 2020 
which exhausted your benefit. After the annual maximum is exhausted, any remaining charges are your 
responsibility. Therefore, we decided that the Plan does not have to pay more for the crown and core buildup 
provided on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on February 4, 2020. 
 
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 surgical pathology services provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on April 8, 2020. 
 
You asked the Plan to pay for back brace. You say that you are appealing with supporting documentation. The 
Plan denied your request. The Plan says the denial of payment for this item is correct, because the 
documentation submitted did not include a face-to-face encounter to support the order for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that documentation of a face-to-face encounter for 
code L0650 is required for payment upon request by the Plan.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a face-to-face 
encounter for this item performed within 6 months prior to the date of the order. Based on this information, we 
decided that Medicare rules for coverage of back brace have not been met. Therefore, we decided that the Plan 
does not have to pay for a back brace (L0650) provided on April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the replacement facemasks (A7031), 
headgear (A7035), and the C-pap full face mask (A7030) provided on May 21, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the durable medical equipment provided. 
 
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 per Medicare-covered durable medical equipment item and related supply.  
 
You have been asked to pay $41.36 ($206.83 Plan allowed amount x 20% coinsurance) for the durable medical 
equipment provided. 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 the replacement facemasks 
(A7031), headgear (A7035), and the C-pap full face mask (A7030) provided on May 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging provided on May 27, 2020. 
 
You asked the Plan to pay for the magnetic resonance imaging, brain (70551). You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says a claim was paid to a different provider within the 
same group and same specialty, therefore modifier -59 is required. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The service was not billed with the -59 modifier, showing the procedure was a distinct procedural service. 
Based on this information, we decided that Medicare rules for coverage of services billed for a distinct 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic 
resonance imaging provided on May 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on May 7, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on May 7, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided by a participating 
provider on April 18, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that this was a hospital transfer. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $120 copayment for emergency care.  
 
The enrollee has been asked to pay a $120 copayment for emergency care. The correct copayment has been 
applied to the services that were provided. Emergency care falls within the emergency care 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 waive the copayment for emergency care provided by a participating 
provider on April 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control 
supplies (S8301) provided on May 26, 2020. 
 
You asked the Plan to pay for the IV tubing extension kit and infection control supplies. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 
codes S1015 and S8301 have a status indicator of I which is not valid for Medicare purposes. 
 
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 codes S1015 and S8301 are not supported in the record. Specifically, per the Physician Fee 
Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and 
S8301 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the IV tubing extension kit and infection control supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control 
supplies (S8301) provided on May 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), 
with any type side rails, with mattress (CPT Code E0260). 
 
You asked the Plan to pre-approve the hospital bed. You say that you need a shorter hospital bed and mattress 
because your current hospital bed is too large for you and it is difficult for you to reach the elevation option by 
your feet. The Plan denied your request. The Plan says the rationale for this determination is not medically 
necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the hospital bed have not been met. Your semi-electric hospital bed 
was issued in 2019, a replacement or new request for similar durable medical equipment does not meet 
Medicare criteria. Therefore, we decided that the Plan does not have to pre-approve hospital bed, semi-electric 
(head and foot adjustment), with any type side rails, with mattress (CPT Code E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
August 27, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician services provided to the enrollee on 
August 27, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on July 13, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for OON home health services. You say that you were told this would be covered. 
The Plan denied your request. The Plan says services must be provided by in-network providers. 
 
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 home health services provided on July 13, 
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transport brackets (CPT Code K0108). 
 
You asked the Plan to pre-approve the transport brackets. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health 
Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
Medicare guidance says the transport brackets are for use outside the home. Equipment intended for use outside 
the home cannot be covered per Medicare rules. The item at issue in this appeal does not serve a purpose that is 
primarily medical in nature. This item is available to the general public and would be helpful even to those who 
are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve transport brackets 
(CPT Code K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair ramp. 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that you are requesting a wheelchair ramp to 
assist with getting up to the porch. The Plan denied your request. The Plan says the wheelchair ramp is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
A wheelchair ramp is not covered because it is not primarily used in the home. The item at issue in this appeal 
does not serve a purpose that is primarily medical in nature. This item is available to the general public and 
would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have 
to pre-approve the wheelchair ramp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 29, 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 services rendered 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 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on February 26, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 26, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on 
February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound behind abdominal cavity (76775) provided on 
February 9, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the ultrasound behind abdominal cavity. You say that these services were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 ultrasound behind abdominal cavity (76775) 
provided on February 9, 2020 by an out of network (OON) provider.