Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous passive motion device (E0935) provided on May 18, 
2019, to June 16, 2019. 
 
You asked the Plan to pay for a continuous passive motion device. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says that the 
documentation submitted did not include a valid physician order indicating length of need and in addition; 
there is no itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery therefore, the 
billed service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare plans must make reasonable and 
diligent efforts to gather and forward information to the Independent Review Entity (IRE). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a continuous passive motion device have been met. In this case, the length of need is not a 
necessary element for the physician order and the member's signature on the rental agreement confirms that this 
equipment was delivered to the hospital to be used at home. It does not appear that the Plan forwarded all of the 
information used to make their decision. Therefore, we decided that the Plan has to pay for a continuous 
passive motion device (E0935) provided on May 18, 2019, to June 16, 2019.  
 
  
 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses provided February 14, 2020. 
 
You asked the Plan to pay for the contact lenses. You say that the eyewear should be covered because the rule 
did not exist prior to 2020. The Plan denied your request. The Plan says the eyewear benefit has been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provides a $100 allowance for eyewear every two years. 
 
We looked at the file and the Plan's rules. The record shows that the $100 allowance was expended on October 
4, 2019. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not 
been met. Therefore, we decided that the Plan does not have to pay for contact lenses provided February 14, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for incision and drainage of abscess (10061) provided November
17, 2019
You asked the Plan to pay for incision and drainage of abscess. You say that you are billing emergency room
provider services which have specific criteria in order to bill appropriately. The Plan denied your request. The
Plan says code not appropriate for service billed.
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 10061 is incision and drainage of abscess (carbuncle,
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single
and complex or multiple.
We find that CPT code 10061 is not supported in the medical record. Specifically, the medical records do not
indicate that the single abscess incised and drained was complicated; therefore, the billed service cannot be
verified. The records show that the plan made multiple attempts to obtain the additional documentation without
success. CPT code 10060 is a more appropriate CPT code that should be used to bill for the service provided.
Based on this information, we decided that Medicare rules for coverage of incision and drainage of abscess
have not been met. Therefore, we decided that the Plan does not have to pay for incision and drainage of
abscess (10061) provided November 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for Hyaluronan 1MJ injections provided on May 5, 2020, and May 13, 2020.
You asked the Plan to waive the cost-sharing for the injections. You say that you feel the charges were for outpatient hospital services when you had the injections done in the physician's office. The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 EOC 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). Review of the file show that Hyaluronan 1MJ injections were administered on May 5, 2020, and May 13, 2020. You have been asked to pay 20% coinsurance of the allowed amount for Medicare-covered Part B drugs per visit. The allowed amount is $1033.50 per visit. The total you owe per visit is $206.70 ($1033.50 x 20% = $206.70). Your EOC states that enrollees must pay 20% coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs. 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 cost-sharing for Hyaluronan 1MJ injections provided on May 5, 2020, and May 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct copayment was 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 $350 
per day copayment after the $1000 deductible is paid for Inpatient Care.  
 
You have been asked to pay a $1,700 copayment for the inpatient hospital care ($1000 deductible, $350 per 
day copayment for 2 days). 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 inpatient hospital care 
provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from June 3, 2020 to June 5, 2020.
You asked the Plan to waive the copayment for these services. You say that the enrollee went to the emergency room for dehydration and fell during discharge. The Plan denied your request. The Plan says the copayment was applied 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each day in a hospital for the first five days for inpatient hospital care.
Review of the file shows that the enrollee received two days of inpatient hospital services from June 3, 2020 to June 5, 2020. The enrollee was not charged a copayment for the date of discharge on June 5, 2020. The enrollee has been asked to pay a $250 copayment for each day in a hospital for these services, for a total of $500. These services fall within the inpatient hospital 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 the inpatient hospital services rendered from June 3, 2020 to June 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from April 28, 2020, through May 19, 
2020. 
 
You asked the Plan to pay for the SNF 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 the enrollee no longer required daily skilled care from either a nurse or a therapist. Continued 
assistance with routine daily activities could be safely provided at the custodial level of care as it had been 
before. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found at the time of the change of condition 
due to an acute infection on April 21, 2020 the enrollee required skilled nursing care with IV fluids, 
supplemental oxygen and frequent assessment. As of April 28, 2020, the enrollee did not require any skilled 
nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable 
and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of 
daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. 
As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of 
care during the period of care under review. She did not have any parental medications, complex wound care or 
nutrition given via a feeding tube. The enrollee received skilled care and improved, however her function had 
improved and plateaued by April 28, 2020 and she did not require any further inpatient skilled services. The 
enrollee's function was at or near her prior level of function and she could be discharged to a lower level of 
care for further services. During the point of care under review the enrollee required custodial services. The 
denial for further inpatient skilled care is upheld. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for SNF services provided from April 28, 2020, through May 19, 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 July 
1, 2019, to July 7, 2019. 
 
You asked the Plan to pay for the SNF services. You say that it is felt that the enrollee continued to require 
SNF level of care. The Plan denied your request. The Plan says daily skilled services are no longer necessary 
during the period at issue. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was hospitalized for 
dyspnea, edema, and atrial fibrillation. She was treated with IV antibiotics which were changed to oral. She 
was discharged to the extended care facility on June 24, 2020 and received SNF care from July 1, 2019, to July 
7, 2019 and the provider is appealing denial of these services.  
 
The patient did not require skilled nursing services with the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment in a SNF during the dates in question. The patient did not have complex wound care or other ongoing 
SNF level skilled nursing needs. The documentation does not support that the patient's functional 
level  required  skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist  to safely and effectively provide medically necessary and reasonable treatment in a SNF. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from July 1, 2019, to July 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from 
November 28, 2019, through December 13, 2019. 
 
You asked the Plan to pay for the inpatient psychiatric hospital services. You say that the admission was 
medically necessary. The Plan denied your request. The Plan says the enrollee could have been treated at an 
outpatient level of care. 
 
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 pay for the inpatient psychiatric hospital services. 
Our reviewer says that the inpatient psychiatric hospital services are not medically necessary. Our physician 
reviewer found that based upon review the records provided it was not expected this enrollee would improve in 
 
 
a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, 
delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to 
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not 
have dangerousness to self or others, perceptual disturbance including delusions, auditory or visual 
hallucinations. The Plans denial of inpatient psychiatric services appears appropriate. This enrollee did not 
appear to require inpatient mental health treatment as he was not a danger to himself or others and was 
cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the 
services were reasonably expected to improve the enrollees condition or for the purpose of diagnosis. The 
enrollee was treated under an individualized treatment plan found in the record. It did appear that the records 
were supervised and evaluated by a physician. Based upon review the records provided for the admission of 
this enrollee, he does not meet the criteria for acute inpatient mental health treatment as this enrollee was not 
shown to be a danger to himself or others but was without agitation or aggression without perceptual 
disturbance including auditory, visual hallucinations or delusions. 
 
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 inpatient psychiatric hospital services have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient psychiatric hospital services provided  from November 28, 2019, through December 13, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper 
or lower extremity arteries and duplex scan services provided on June 9, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the limited bilateral noninvasive physiologic studies of upper or lower extremity 
arteries and duplex scan 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. 
 
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 limited bilateral noninvasive physiologic 
studies of upper or lower extremity arteries and duplex scan services provided on June 9, 2020 by an out of 
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient level of care provided. 
 
You asked the Plan to pay for the inpatient level of care. You say that the inpatient level of care was medically necessary. 
The Plan denied your request. The Plan says  
the enrollee was stable for transfer to an in-network facility for further care. 
 
 
 
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 the inpatient level of care. Our reviewer says 
that the inpatient level of care provided  was not medically necessary.
 Our physician reviewer found the review indicates that the enrollee was hemodynamically stable 
and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission level of 
care services after the emergency room evaluation. The post-stabilization care services
were not medically necessary or reasonable. The review has determined that the treating physician did not 
document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any 
dates of service. 
 
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 inpatient level of care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient level of care provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient services provided on January 27, 2020, through January 29, 2020. You asked the Plan to pay forthe inpatient services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says precertification/authorization is absent. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Specifically, the documentation submitted does not include medical records for the billed dates of service. Therefore, we decided that the Plan does not have to pay for inpatient services provided on January 27, 2020, through January 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on April 29, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you had to go in order to get a 
scooter. You say that you did not want to go. 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 $20 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $20 copayment for physical therapy. Physical therapy services were provided; 
therefore, the correct copayment has been applied. Physical therapy falls within the outpatient rehabilitation 
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 physical therapy provided 
by a participating provider on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the 20% coinsurance charged for Medicare Part B 
drugs provided on March 23, 2020. 
 
You asked the Plan to waive or reduce this coinsurance. You say that you do not believe this cost share is 
correct. The Plan denied your request. The Plan says this coinsurance was charged based on the drugs and 
services provided and the Plan contact agreement. 
 
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% 
coinsurance for Medicare Part B drugs.  
 
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 or reduce the 20% coinsurance charged for Medicare Part B drugs provided on March 
23, 2020.