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

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 21, 
2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges 
because this was your annual wellness visit. 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 $10 
copayment for primary care provider visits.  
 
The medical records show that you received services beyond an annual wellness visit on September 21, 2020. 
Therefore, you are responsible to pay the $10 copayment.  
 
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the 
physician/practitioner services, including doctor's 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 an office visit provided on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
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. 
 
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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does not require an intensive inpatient rehabilitation therapy 
program. Care at the skilled nursing facility level appears to be appropriate in this case. 
 
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) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from January 
23, 2020, to January 24, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules 
to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the medical records show the enrollee had a history significant for cardiac stent who presented 
to the emergency department with left-sided chest pain radiating down left arm and back, shortness of breath, 
headache, nausea for 2 hours prior to arrival. ECG showed ST elevations. He was given morphine and Zofran. 
He was place under observation for cardiology consultation and monitoring. He was upgraded to inpatient 
status as chest pain persisted and worsened, rated 10 out of 10 VAS and plans for catheter were made for the 
next morning. He was transferred to a higher-level cardiac center for catheter and possible angioplasty 2 days 
after admission. After the patient appeared to be failing treatment under observation with pain worsening, due 
to the severity the patient was expected to require hospital care that would cross 2 midnights total. We looked 
at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to 
pay for the acute inpatient hospital care provided to the enrollee from January 23, 2020, to January 24, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that since your knee surgery it is difficult to sit in the bath. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization care provided to the enrollee from June 11, 
2020, to June 12, 2020. 
 
You asked the Plan to pay for post stabilization care for the enrollee. You say that this service should be 
covered by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria for post 
stabilization care were not met as of 3:54 pm on June 11, 2020. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for this service. Our reviewer 
says that Medicare coverage criteria are not  met. Our physician reviewer found the medical records show the 
enrollee arrived at the emergency department following a near syncopal episode and weakness while getting 
out of bed the same day.  
She was treated with transfusion, fluids, antibiotics and had EGD on June 11, 2020. The GI stated that there 
was no acute bleeding seen. The enrollee appeared to be stable during the hospitalization and there was no 
documentation of not being stable at any time. The documentation stated that following the EGD, the enrollee  
was hemodynamically stable, with no acute bleeding, and was stable for discharge (after 3:54 pm) on June 11, 
2020. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided 
that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for post stabilization care provided to the enrollee from June 11, 2020, to June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair. 
 
You asked the Plan to pre-approve a stair glide. You say that there are levels in your home and have a very 
hard time getting up and down stairs. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that these supplies are medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0140, D0330) provided to the enrollee on 
September 8, 2020. 
 
You asked the Plan to pay for the services. You say that payment should be reconsidered. The Plan denied your 
request. The Plan says the benefits for these services have been exhausted. 
 
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. The Plan covers dental 
services with certain utilization guidelines. 
 
A panoramic x-ray (D0330) was provided less than five years ago on April 23, 2018. Oral exams were last 
received twice in the last year on January 20, 2020 and September 2, 2020. Based on this information, we 
decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for dental services (D0140, D0330) provided to the enrollee on September 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee and billed under DRG 871.

You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says the records provided do not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for this claim. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the medical records show the enrollee was reported to have shortness of breath. A nosocomial condition was diagnosed. The enrollee presented with fever and suspected aspiration. The sequential organ failure assessment score criteria score was less than 2. She appeared to be near her baseline COPD. There was insufficient evidence to support the diagnosis of sepsis or acute respiratory failure. Therefore, the DRG 871 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG . Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee and billed under DRG 871.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy evaluation (97162) electrical stimulation 
unattended (G0283) provided on September 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the physical therapy services. You say that your office, individual providers and 
referring providers are participating providers with Medicare. Please review all documentation and approve 
your services for payment, as these services were medically necessary. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 had network providers 
available who could have provided 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 physical therapy evaluation (97162) electrical 
stimulation unattended (G0283) provided on September 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 21, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that you would like reconsideration because this 
provider should be authorized as a podiatrist and the appointment should be deemed necessary for routine foot 
care. The Plan denied your request. The Plan says these services are available within the Plan's network of 
providers are are not covered under the terms of your EOC. 
 
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 had network providers 
available who could have provided 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 October 21, 2020 
by an out of network (OON) 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 enrollee would benefit from care in 
the LTACH rather than remaining in the intensive care unit. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate care, and there is no clinical benefit to transfer to an LTACH. 
 
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 the patient is an 81 year old female who was admitted to the current acute care 
hospital with acute on chronic respiratory failure due to chronic obstructive pulmonary disease exacerbation 
requiring intubation. She underwent tracheostomy and feeding tube placement. Oxygen is being weaned 
currently and she is tolerated tube feeds but diagnosed with septic shock and urinary tract infection requiring 
midodrine, norepinephrine infusion. and antibiotics.  
 
It appears that the patient is unstable and requires short term additional acute care services to stabilize which 
can be safely be received at the current facility until completed. The patient does not require services at the 
LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the limited oral exam, the porcelain/ceramic crown, re-
cement of a crown, core buildup and a periapical x-ray provided on June 23, 2020. 
 
You asked the Plan to pre-approve these services. You say that you would like payment made for these 
services. The Plan denied your request. The Plan says that these services are not covered. 
 
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. The Plan covers these services 
when the services are medically necessary and reasonable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these services have not been met. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the limited oral exam, the porcelain/ceramic crown, re-cement of a crown and 
core buildup are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve the limited oral exam, the porcelain/ceramic crown, re-cement of a crown, core buildup and a 
periapical x-ray provided on June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81408 and 81479) provided on June 
16, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 tests at issue in this appeal, the laboratory services (81408 and 81479), were requested solely for screening 
purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (81408 and 81479) provided on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRI of the breast (77049) provided on October 12, 2020. 
 
You asked the Plan to pay for the MRI of the breast. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 77049 is not payable under the 
Hospital Outpatient Prospective Payment System (OPPS). 
 
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 77049 is not supported in the record. Specifically, per OPPS, CPT code 77049 has a 
status indicator of B. This means that CPT code 77049 is not recognized by OPPS when submitted on an 
outpatient hospital Part B bill type (12x and 13x). Based on this information, we decided that Medicare rules 
for coverage of the MRI of the breast have not been met. Therefore, we decided that the Plan does not have to 
pay for the MRI of the breast (77049) provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service  (99443) 
provided on August 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON telephone evaluation and management service. You say that this is 
supported by the records. The Plan denied your request. The Plan says this was 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 had network providers 
available who could have provided 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 telephone evaluation and management service  
(99443) provided on August 27, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator system (E0466) and high frequency 
chest wall oscillator (E0483). 
 
You asked the Plan to pre-approve the home ventilator system and high frequency chest wall oscillator. You 
say that you would like reconsideration because you require nocturnal and daytime volume ventilation. The 
Plan denied your request. The Plan says you do not have a confirmed diagnosis of bronchiectasis and there is 
no evidence that the requested mechanical ventilator is needed. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
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 home ventilator system and high 
frequency chest wall oscillator. Our reviewer says that you do not require full ventilator supper day and night. 
Our physician reviewer found the oscillation device is not supported as there was no evidence of you having 
bronchiectasis or other chronic condition which might warrant long-term use of the clearing vest. 
 
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 home ventilator system and high frequency chest wall oscillator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator system 
(E0466) and high frequency chest wall oscillator (E0483).