Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the home physical therapy services provided on March 10, 
2020 billed with code S9131. 
 
You asked the Plan to pay for the home therapy. You say that this claim should be paid since these services do 
not require authorization. The Plan denied your request. The Plan says this is not a Medicare-certified provider 
so the claim cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code S9131 has a status indicator of "I" in the Physician Fee Schedule. This means it is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home 
therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home physical 
therapy services provided on March 10, 2020 billed with code S9131.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on February 17, 
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 17, 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 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hep A-Hep B vaccine provided on April 13, 2020. 
 
You asked the Plan to pay for the vaccine. You say that you would like reimbursement. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the Hep A-Hep B vaccine provided on April 13, 
2020.  
 
Benefits for the vaccine 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: Practitioner Services
Decision: Partially Favorable

You asked the Plan to waive the copayment for office visit. You say that this was a preventive visit with your 
primary care provider, so this copayment is incorrect. The Plan says that the copayment amount you are being 
charged is correct. 
 
We decided that the Plan has to reduce the copayment for this office visit.  
 
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 enrollees must pay $20 copayment for each in-network primary care visit, 
including telehealth services. The rendering physician is a primary care physician and not a specialist; 
therefore, the specialist visit copayment does not apply to this claim.  
 
The Plan says you must pay $45 copayment for primary care visit. Based on the Plan contract, however, you 
cannot be asked to pay more than $20 copayment for primary care visit. Therefore, we decided that the Plan 
has to reduce the copayment for office visit from $45 to $20.  
 
We also decided that the Plan does not have to waive the copayment for office visit. 
 
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 $20 
copayment for each in-network primary care visit. This visit included a non-routine diagnosis and this visit was 
not preventive in nature, therefore an office visit copayment applies to this claim. Therefore, we decided that 
the Plan does not have to waive the copayment for office visit. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 19, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on June 19, 2020 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 24, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 43499 is not supported. 
 
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 43499 is other procedures on the esophagus. 
 
We find that CPT code 43499 is not supported in the medical record. Specifically, there is no documentation of 
a report describing the services rendered. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical services rendered on June 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 16, 2020 to March 18, 2020. 
 
You asked the Plan to pay for home health services. You say that this should be acceptable on the form used. 
The Plan denied your request. The Plan says this was not billed on the correct form. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, these 
services were not billed with the required revenue code. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from March 16, 2020 to March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on June 11, 2020. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you should be 
reimbursed for these services. The Plan denied your request. The Plan says the provider in this case has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
established patient office or other outpatient visit (99214) provided on June 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for Home Health services provided from April 6, 2020, to May 
27, 2020. 
 
You asked the Plan to pay for the Home Health services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the enrollee was in inpatient services during some of the claim dates of 
service. 
 
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 G01551 is Services performed by a qualified physical 
therapist in the home health or hospice setting. 
 
We find that the enrollee was an inpatient at the time of some of the claimed dates of service. Based on this 
information, we decided that Medicare rules for coverage of the Home Health services have not been met. 
Therefore, we decided that the Plan does not have to pay for Home Health services provided from April 6, 
2020, to May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 85025, 86140, 
G0463) provided on February 25, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained 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 laboratory services (36415, 80053, 85025, 
86140, G0463) provided on February 25, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on February 10, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that the test was not completed. 
You say that you should not have to pay for something that was done. 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). Your contract with the Plan clearly says that you must pay a $25 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $25 copayment for specialist services. This copayment is for a specialist office 
visit, not a diagnostic test. Specialist services fall within the physician/practitioner services/in-
network/specialist 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 specialist services 
provided by a participating provider on February 10, 2020.  
 
Your quality of care concerns have been handled separately by the Plan. Medicare does not permit us to make a 
decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care and discharge rendered on April 
18, 2020 and April 22, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for an initial observation care code is for all 
the care rendered by the ordering physician on the date the patient's observation services began. 
 
We looked at the file and Medicare rules. The file shows that procedure codes 99220 (initial observation care) 
and 99217 (observation discharge) were billed with other evaluation and management codes by the same 
provider. The Plan paid the previous evaluation and management codes; therefore, payment for 99220 and 
99217 cannot be made. Therefore, we decided that the Plan does not have to pay for the initial observation care 
and discharge rendered on April 18, 2020 and April 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
December 23, 2019 to December 31, 2019. 
 
You asked the Plan to pay for the SNF services. You say that this was the only facility would accept the 
enrollee. The Plan denied your request. The Plan says that providers must be eligible for Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who 
is not enrolled in the Medicare Program. 
 
These services were not provided by a facility that is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from December 23, 
2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the external ambulatory insulin delivery system (A9374) 
provided on July 16, 2020. 
 
You asked the Plan to pay for the external ambulatory insulin delivery system. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code A9374 
has 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 code A9374 is not supported in the record. Specifically, per CMS, CPT code A9374 has a 
status indicator of I. This means that CPT code A9374 is not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of the external ambulatory insulin delivery system 
have not been met. Therefore, we decided that the Plan does not have to pay for the external ambulatory insulin 
delivery system (A9374) provided on July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for routine disposable supplies *A0398) provided on January 27, 
2020. 
 
You asked the Plan to pay for the routine disposable supplies. You say that you would like reconsideration 
because this service was billed correctly. The Plan denied your request. The Plan says the disposable supplies 
does not meet the requirements for approval. 
 
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 A0398 is not supported in the record. Specifically, items and supplies are no longer 
paid separately for ambulance services and payment is based solely on the ambulance fee schedule. Based on 
this information, we decided that Medicare rules for coverage of the routine disposable supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for routine disposable supplies *A0398) 
provided on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 87633) provided on April 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that LCA A57579 provides a list of non-covered CPT 
codes.  
 
We looked at the file and Medicare rules. Per A57579, CPT code 87633 is non-covered. 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 the services (CPT 87633) provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on December 31, 2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the enrollee 
did not have an indication for the procedure to be performed under monitored anesthesia care. 
 
The Plan must follow Medicare rules. Medicare rules say that monitored anesthesia care for lumbar epidural 
injections are only covered under certain medical indications.   
 
We looked at the file and Medicare rules. The records provided do not clearly establish the need for such 
sedation in this enrollee. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on 
December 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health admission. 
 
You asked the Plan to pre-approve inpatient behavioral health admission. You say that the enrollee is very 
much in need of inpatient treatment to reach optimal level of life. The Plan denied your request. The Plan says 
the records do not support that inpatient care is medically necessary. Care can be received through outpatient 
services. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavioral health admission. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this enrollee did not appear to require inpatient mental health 
treatment as she was not a danger to herself or others and was cooperative with care without any aggressive 
behaviors. It did not appear that active treatment was taking place. It did not appear that the services were 
reasonably expected to improve the patient's condition or for the purpose of diagnosis. I am unable to find an 
individualized treatment found however the entire record is not present. It did appear that the records were 
supervised and evaluated by a physician. Based upon review the records provided for the admission of this 
patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to 
herself or others, auditory or visual hallucinations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health admission.
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 you would like reconsideration because COVID 
cases are increasing and switching facilities puts you at more risk of being exposed to the virus. The Plan 
denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies in an intensive rehabilitation therapy program. There is not a reasonable 
expectation that you 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT Scan. 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because you are 
losing weight and not able to gain it back. The Plan denied your request. The Plan says there is no evidence that 
a thorough workup has been done. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT Scan. Our reviewer says that 
medical necessity is not met for the CT imaging indication cited and as requested in this case. Our physician 
reviewer found clinicals as provided do not specify time-frames nor results of previous abdominal imaging, and 
as such do not support medical appropriateness of additional imaging by CT scan 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 CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT Scan.