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

 
We decided that the Plan does not have to pay for the Jazzy scooter received on February 20, 2020. 
 
You asked the Plan to pay for the Jazzy scooter. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Jazzy scooter. Our reviewer says that the 
documentation does not support that the item received was medically reasonable or necessary. Our physician 
reviewer found the documentation does not support that the enrollee has a personal mobility deficit that impairs 
participation in mobility-related activities of daily living. The documentation does not support that the enrollee 
has a mobility deficit that cannot be helped by the use of a walker, cane or manual wheelchair. The 
documentation does not support that the item received was medically reasonable or necessary. 
 
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 Jazzy scooter have not been met. Therefore, we decided that the Plan does 
not have to pay for the Jazzy scooter received on February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 12, 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 codes 80177, 80157, 80159, 80173, 80162, and 80201 are 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. 
 
We find that CPT codes 80177, 80157, 80159, 80173, 80162, and 80201 are not supported in the medical 
record. Specifically, the records show that a urine specimen was collected, not a blood specimen. 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 laboratory services rendered on May 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic mammogram and breast 
ultrasound you had on August 3, 2020. 
 
You asked the Plan to waive the copayments for the diagnostic mammogram and breast ultrasound. You say 
that you have had this service in the past and haven't had to pay a copayment. The Plan denied your request. 
The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for basic imaging services.  
 
You have been asked to pay a $40 copayment for both the diagnostic mammogram and breast ultrasound. Both 
of these services fall within the basic imaging 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 copayments for the diagnostic mammogram and breast ultrasound you had on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the cystourethroscopy procedures you had 
at an outpatient hospital facility on May 8, 2020, and August 14, 2020. 
 
You asked the Plan to waive the copayments for the cystourethroscopy procedures. You say that you have had 
this procedure in the past and no copayment applied. The Plan denied your request. The Plan says these 
copayments were appropriately 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 $400 
copayment for surgery and services at an outpatient hospital facility.  
 
You have been asked to pay a $400 copayment for the cystourethroscopy procedures. The cystourethroscopy 
procedures fall within the surgery and services at an outpatient hospital facility benefit category. These 
copayments apply regardless of whether you have been charged in the past. 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 copayments for the cystourethroscopy procedures you had at an outpatient hospital facility on May 
8, 2020, and August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the SCS is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain 
that is axial in nature. She received no pain relief from diagnostic medial branch blocks. She has no history of 
spinal surgery or other evidence-based indications for the SCS. The services are not reasonable or medically 
necessary. 
 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve golf cart fees. 
 
You asked the Plan to pre-approve the fees. You say that this should be paid for. The Plan denied your request. 
The Plan says golf cart fees are considered equipment rental, and not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers gym benefits, 
but not golf club benefits. 
 
The Plans rules for coverage of gym benefits have not been met because these are golf club benefits. 
Therefore, we decided that the Plan does not have to pre-approve golf cart fees.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit you had on December 
10, 2019. 
 
You asked the Plan to waive the copayment for the dermatology visit. You say that you feel as though the 
doctor waited to long to bill you for this copayment. The Plan denied your request. The Plan says you were 
charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for specialty care services.  
 
You have been asked to pay a $40 copayment for the dermatology visit. The dermatology visit falls within the 
specialty care 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 the 
dermatology visit you had on December 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy provided from September 
3, 2019, through October 24, 2019. 
 
You asked the Plan to waive the copayments for physical therapy. You say that you paid your copayment each 
time. You say that you want to know why you owe more. The Plan denied your request. The Plan says the 
copayments were 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). Your contract with the Plan clearly says that you must pay a $25 
copayment for each Medicare-covered physical therapy and speech-language therapy visit. 
 
You have been asked to pay a $25 copayment for each physical therapy visit. The total amount you owe is 
$375 ($25/ visit x 15 visits = $375). 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 copayments for physical therapy provided from 
September 3, 2019, through October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 29, 2020. 
 
You asked the Plan to pay for the physician's 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 
physicians services. 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 physician's services provided on April 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. There is concern that the patient will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF due to the patient's pain, requirements for rest breaks with 
therapy and oxygen desaturations with therapy. Care at the skilled nursing facility level appears to be more 
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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies with CPT codes A6222 and A6446 provided on 
December 12, 2019. 
 
You asked the Plan to pay for the supplies with CPT codes A6222 and A6446. 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 must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
CPT code A6222 has a status indicator of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for these codes under the fee schedule as payment is bundled into 
the payment for the services to which these codes are incident to. CPT code A6446 has a status code of "X" 
under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee 
 
 
schedule payment purposes. Based on this information, we decided that Medicare rules for coverage of the 
supplies with CPT codes A6222 and A6446 have not been met. Therefore, we decided that the Plan does not 
have to pay for the supplies with CPT codes A6222 and A6446 provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on June 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 the medical services provided to you by an out-of-network provider on June 10, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 2, 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 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291, 99292) provided May 27, 2020 
to May 28, 2020. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the services 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. 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, CPT codes 
99291 and 99292 are time based. The provided records do not show how much time was spent on the critical 
care services. Based on this information, we decided that Medicare rules for coverage of the critical care 
services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services 
(99291, 99292) provided May 27, 2020 to May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services (11045) provided June 25, 2020. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the add-on code billed did not include an approved primary code. 
 
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 11045 is not supported in the medical record. Specifically, CPT code 11045 was billed 
as an add-on code to the primary procedure 11042. The primary procedure was denied for not including a valid 
diagnosis code. Since the primary code was denied, the add-on code has also been denied. Based on this 
information, we decided that Medicare rules for coverage of the wound care services have not been met. 
Therefore, we decided that the Plan does not have to pay for wound care services (11045) provided June 25, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient rehabilitation services provided on October 4, 
2019 to October 10, 2019. 
 
You asked the Plan to pay for the inpatient rehabilitation services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the non-emergent services were not pre-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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 the inpatient rehabilitation services provided on October 4, 2019 to October 10, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. The Plan denied your request. The Plan 
says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy for this condition 
and does not require the unique skills of a professional therapist to safely and effectively provide ongoing 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready pending approval. The Plan 
denied your request. The Plan says your request for approval of an IRF admission does not meet the 
requirements for approval. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does require physical therapy and occupational therapy services, but based on the 
medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. 
Our physician reviewer also found that there is concern that the enrollee will not be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF due to decreased endurance 
and lightheadedness with therapy. Care at the skilled nursing facility level appears to be more 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 acute IRF admission and services.