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

 
We decided that the Plan does not have to pay for nurse practitioner services provided on February 27, 2020. 
 
You asked the Plan to pay for the nurse practitioner 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 
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 nurse practitioner services provided on February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (HIT) administrative services 
provided from December 12, 2019, to March 5, 2020 billed with code S9328. 
 
You asked the Plan to pay for the HIT services. You say that this infusion therapy should be covered as 
medically necessary for the enrollee's severe pain. The Plan denied your request. The Plan says this code is not 
valid for Medicare billing and payment. 
 
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 S9328 has a status indicator of "I" in the Physician Fee Schedule. This means that it is invalid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services 
have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy 
(HIT) administrative services provided from December 12, 2019, to March 5, 2020 billed with code S9328.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for wound debridement services you received at the provider from March 2, 2020, through May 18, 2020. 
 
You asked the Plan to reduce the copayment for the wound debridement services.. You say that you did not 
have these services at the hospital - you had them at a wound care clinic. The Plan denied your request. The 
Plan says that you were charged the outpatient hospital surgery copayment correctly. 
 
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 a $225 copayment for surgery in an outpatient hospital 
facility and a $25 copayment for surgery services in a specialist's office.  
 
The Plan says you are responsible for the outpatient hospital surgery copayment of $225 for each date of 
service for the wound debridement services. We do not find this argument persuasive.  The Plan says that you 
are responsible for the outpatient hospital surgery copayment.  However, we find that these services did not 
occur at an outpatient hospital facility.  Rather, they occurred at the provider.  
According to the provider website, the address for this wound care center does not match the address of 
any hospital within their group.  Rather, this wound care center is located at an outpatient office facility. That is why we find that these services were not rendered at a hospital, but were rendered in an office setting.  As a result, applying the outpatient hospital copayment is not appropriate here.  Although this wound care center may have billed these services as an outpatient hospital facility, there would have been no way for you as a patient to know that. It is only appropriate for you to be 
charged the specialist visit copayments for these services. Therefore, we decided that the Plan has to reduce the 
copayment for wound debridement services you received at provider from March 2, 2020, through May 18, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on June 1, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing 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. 
 
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 
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 skilled nursing services provided on June 1, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement services 
provided on November 14, 2019. 
 
You asked the Plan to pay for the fluoroscopic guidance for needle placement services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
payable. 
 
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 77002 is fluoroscopic guidance for needle placement (eg, 
biopsy, aspiration, injection, localization device).
 
We find that CPT code 77002 is not supported in the medical record. Specifically, code 77002 was billed 
without an appropriate primary code. Based on this information, we decided that Medicare rules for coverage 
of the fluoroscopic guidance for needle placement services have not been met. Therefore, we decided that the 
Plan does not have to pay for the fluoroscopic guidance for needle placement services provided on November 
14, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid services coded 
87633 provided on April 30, 2020. 
 
You asked the Plan to pay for infectious agent detection by nucleic acid services. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that infectious agent detection by nucleic acid 
services identified with code 87633 are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infectious agent detection by nucleic acid services have not been met. Therefore, we decided that 
the Plan does not have to pay for infectious agent detection by nucleic acid services coded 87633 provided on 
April 30, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on July 11, 2019. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to the ER 
because your doctor recommended it. You say that you were there for hours and got sent back home with pain. 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was 
provided, the correct copayment has been applied. An emergency room visit falls within the emergency care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit 
provided by a participating provider on July 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services you 
received from April 1, 2020, through May 7, 2020. 
 
You asked the Plan to waive the copayments for the outpatient rehabilitation services. You say that these 
copayments should be waived due to COVID-19. The Plan denied your request. The Plan says the copayment 
waiver policy is only in effect from May 11,2020, through September 30, 2020. The plan says that the services 
you received from May 11, 2020, through May 31, 2020, have not been assessed a copayment. However, the 
other days of service were provided before the waiver went into effect, so you were charged these amounts 
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 $15 
copayment for each outpatient rehabilitation visit.  
 
You have been asked to pay a $15 copayment for each of the outpatient rehabilitation services you received 
from April 1, 2020, through May 7, 2020.  In this date span, you had a total of 10 visits, so you were assessed a 
total copayment obligation of $150. 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 outpatient 
rehabilitation services you received from April 1, 2020, through May 7, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (93010, 99285) provided February 
27, 2019. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim was not filed within the allowable timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency room services was not filed until July 6, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for emergency room services (93010, 99285) provided February 27, 
2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services (90834) provided 
March 24, 2020. 
 
You asked the Plan to pay for the outpatient mental health services. 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 item/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 outpatient mental health services (90834) provided March 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90833) services provided on May 5, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that the provider gave you misinformation regarding 
their network status. The Plan denied your request. The Plan says in order to see an out-of-network provider, 
there must be an approved referral from your primary care physician.  
 
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 psychotherapy (90833) services provided on 
May 5, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 1, 2019. 
 
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 
physician's 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 August 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for eyeglasses (V2299, V2744, V2781) provided on 
June 17, 2020. 
 
You asked the Plan to pay the full cost for eyeglasses. You say that this should be covered. The Plan denied 
your request. The Plan says this processed correctly. 
 
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 offers a $250 allowance for supplemental eyewear every year. Members are responsible for 
all costs over and above the allowance amount. 
 
We looked at the file and the Plan's rules. The retail price for the eyeglasses at issue was $790. The plan paid 
the $250 specified in the contract. Contractual adjustments with the network provider lowered the remaining 
cost from $540 to $432. You are responsible for this remaining cost according to your contract with the Plan. 
Therefore, we decided that the Plan does not have to pay the full cost for eyeglasses (V2299, V2744, V2781) 
provided on June 17, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from July 7, 2019, to 
August 6, 2019. 
 
You asked the Plan to pay for the skilled nursing 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 
does not meet Medicare guidelines for SNF continuation. 
 
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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from July 7, 2019, to August 6, 2019.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of a traumatic brain injury, seizure disorder and urinary tract infections who is non-verbal, fed 
via a percutaneous feeding tube and bedbound at baseline who presented to the acute hospital on 09/05/2020 
with persistent seizure activity. She developed respiratory failure, pneumonia and sepsis and was treated in the 
hospital with intubation, mechanical ventilation, anti-seizure medications, intensive care unit monitoring and 
intravenous antibiotics. She had a tracheostomy placed. She reportedly does not open eyes, track or follow 
commands. She has been evaluated by physical therapy. She is totally dependent for transfers and activities of 
daily living. She is otherwise medically stable. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require the physical therapy and occupational therapy services provided in an intensive 
inpatient rehabilitation therapy program. Based on the medical records provided there is no documentation that 
the enrollee is able to participate in and benefit from the intensive rehabilitation therapy program provided in 
an inpatient rehabilitation facility. 
 
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 medical services provided on February 25, 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 February 25, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal pillows provided for use with a continuous positive 
airway pressure (CPAP) device on February 24, 2020. 
 
You asked the Plan to pay for the nasal pillows. You say that this claim should be paid as billed. The Plan 
denied your request. The Plan says the number of billed units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 6 units of CPT code A7033 are not supported in the medical record. The medical record only 
supports 5 units of CPT code A7033. Based on this information, we decided that Medicare rules for coverage 
of the nasal pillows have not been met. Therefore, we decided that the Plan does not have to pay for the nasal 
pillows provided for use with a continuous positive airway pressure (CPAP) device on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to refund the coinsurance for CPAP accessories (A7035, A7038, 
A7033, A7037) provided February 19, 2020 to May 19, 2020. 
 
You asked the Plan to refund the coinsurance for the CPAP accessories. You say that the items were returned 
so you should be refunded the cost. The Plan denied your request. The Plan says the items were provided and 
were opened prior to being returned. The correct cost-sharing 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 20% 
coinsurance for Durable Medical Equipment.  
 
You have been asked to pay a 20% coinsurance for the CPAP accessories. The CPAP accessories falls within 
the Durable Medical Equipment 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 refund the coinsurance for 
CPAP accessories (A7035, A7038, A7033, A7037) provided February 19, 2020 to May 19, 2020.