Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided January 31 to February 6, 
2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the inpatient services were provided out-of-network and the 
provider did not request authorization for the services in a timely fashion. 
 
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 hospital care. Our reviewer 
says that the services at issue do not meet coverage criteria. Our physician reviewer found the patient was 
stable to transfer by ambulance to a network hospital when the Emergency Department evaluation was 
complete. 
 
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 hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital care provided January 31 to February 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to you from January 28, 2020, to 
March 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is 
not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. The provider in question is a licensed profession counselor. This type 
of provider is not eligible to enroll in the Medicare program, and therefore is not eligible for payment. 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 provided to you from January 28, 2020, to March 5, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 16, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 7, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan requires prior authorization for specialist's visits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 7, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee benefits from physical therapy. The 
Plan denied your request. The Plan says that due to the member's persistent low level of function and 
progressive ongoing decline, she is not a candidate for skilled therapy at a SNF. 
 
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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you require additional 
trips. The Plan denied your request. The Plan says that you have exhausted this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings provided on March 11, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the bitewings. You say that the bitewing x-rays should be covered because your 
dentist office changed your original appointment. You also say that had the original appointment been kept, the 
x-rays would have been covered. The Plan denied your request. The Plan says you exceeded the frequency 
limitations for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, bitewing x-rays are limited to one set 
every 12 months. The record shows that you received bitewing x-rays on March 12, 2019 and your bitewing x-
rays benefit had been exhausted for the time period. This service was performed by an OON provider. Prior 
authorization was not obtained from the Plan, so the Plan did not have the opportunity to give you prior notice 
that this service would not be covered. Therefore, we decided that the Plan does not have to pay for the 
bitewings provided on March 11, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
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 may require skilled physical therapy and occupational therapy but 
based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation 
therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212), electrical stimulation (G0283), and
the hot or cold packs therapy (97010) provided on February 24, 2020.
You asked the Plan to pay for the office visit, electrical stimulation, and the hot or cold packs therapy. You say
that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The
Plan says these services are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the office visit (99212), electrical stimulation (G0283), and the hot or
cold packs therapy (97010) provided on February 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services (CPT 73060) provided to the enrollee on 
March 10, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the diagnosis codes associated to this code are mismatched to the procedure modifier on the 
claim line. 
 
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 73060 is "Radiologic examination; humerus, minimum of 
2 views." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not coded correctly. Our coding reviewer found the provider billed CPT 
73060 with modifier RT, with diagnosis ICD 10 code S42.309A Unspecified fracture of shaft of humerus, 
unspecified arm. CPT 73060 with modifier RT, is mismatched to ICD 10 S42.309A, as, it is not appropriate to 
assign an unspecified ICD 10 diagnosis code with a specified left, right or bilateral modifier. 
 
We looked at this coder's review, the file, and Medicare rules. 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 x-ray services (CPT 73060) provided to the enrollee on March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee can get severe infections, go to the 
hospital, and get septic. 
 The Plan denied your request. The Plan says the Medicare-approved sources do not support this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 services. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is not 
currently on any immunosuppressive chemotherapy and there is no compendia or literature support for 
prophylaxis of persistent afebrile neutropenia without such therapy. This enrollee has drug induced 
neutropenia. The review has determined that the documentation does not support that the drug is medically 
reasonable and necessary for the enrollee. The documentation does not support that the drug is safe and 
effective for the enrollee. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Udenyca for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non covered chiropractic services provided from April 
23, 2020 to April 30, 2020. 
 
You asked the Plan to pre-approve these services. You say that you believed these services were covered. The 
Plan denied your request. The Plan says any services provided that are not directly related to manual 
manipulation of the spine are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve non covered chiropractic services provided from April 23, 2020 to April 
30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 7, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 drug testing services provided on July 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on January 21, 
2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you 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 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 out of network physician services provided on January 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
March 9, 2020. 
 
You asked the Plan to pay for this claim. 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 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 out of network physician services provided to the enrollee on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits and the 
diagnostic tests provided on April 9, 2019 and October 14, 2019. 
 
You asked the Plan to waive the copayments for the specialist office visits and the diagnostic tests. You say 
that these tests are medically necessary and you have never been charged for these tests before. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 $40 
copayment for each covered in-network specialist office visit and a $65 copayment for each covered diagnostic 
procedure or test at a network doctor's office.  
 
You have been asked to pay a total of $142.19 for the specialist office visits and the diagnostic tests. The 
specialist office visits fall within the Physician/Practitioner services, including doctor's office visits benefit 
category. The diagnostic tests fall within the Outpatient diagnostic tests and therapeutic services and supplies
benefit category. See chart below. 
  
Date of Service Service Allowed Amount Copayment Member Liability 
April 9, 2020 Specialist office 
visit 
$104.61 $40.00 $40.00 
October 14, 2019 Specialist office 
visit 
$104.61 $40.00 $40.00 
October 14, 2019 Gonioscopy $21.23 $65.00 $21.23 
October 14, 2019 Ophthalmic 
diagnostic imaging 
$40.96 $65.00 $40.96 
Total    $142.19 
 
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 specialist office visits and the diagnostic tests provided 
on April 9, 2019 and October 14, 2019. 
 
Our decision is only about the April 9, 2019 and October 14, 2019 services. If you have any questions about 
prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment purchased on February 27, 2020 
out of network.  
 
You asked the Plan to pay for this equipment. You say that you were told there would be no charge. The Plan 
denied your request. The Plan says the cost of this equipment was applied to your deductible which had not 
been satisfied at the time of purchase. 
 
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 there is $500 deductible that must be paid before the Plans pays its share of 
your care and services.  
 
You purchased durable medical equipment out of network.  The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible. This cost sharing is a contractual obligation that had not 
been met at the time this equipment was received. Therefore, we decided that the Plan does not have to pay for 
durable medical equipment purchased out of network on February 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99309) provided on March 9, 2020.
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The
Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network
providers available.
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 nursing facility care (99309) provided on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
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 may require skilled physical therapy and occupational therapy but 
based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation 
therapy program. 
 
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.