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

 
We decided that the Plan does not have to waive the copayment for an urgent care visit (99203) on January 3, 
2020. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that the enrollee's diagnosis 
indicates this service was related to COVID-19. 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 $40 
copayment for each urgently needed visit in a non-contracted Urgent Care Center or walk-in clinic in the 
United States.  
 
You have been asked to pay a $40 copayment for an urgent care visit. An urgent care visit falls within the 
"Urgently Needed Services" benefit category. The case record documents that the diagnosis associated with 
this date of service was bronchitis, not COVID-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 copayment for 
an urgent care visit (99203) on January 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on April 7, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the diagnosis codes billed on the claim are 
mismatched. 
 
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 71045 is not supported in the record. Specifically, there is a more appropriate diagnosis 
code to indicate that the condition was bilateral. Based on this information, we decided that Medicare rules for 
coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the 
chest x-ray (71045) provided on April 7, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that your 
functional status requires an intensive rehabilitation therapy program provided in an IRF. 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 days of home health aide services for nursing 
evaluation and treatment. 
 
You asked the Plan to pre-approve home health aide services. You say that the home health aide services are 
medically necessary. The Plan denied your request. The Plan says the clinical information did not support the 
medical necessity for this service. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health aide services. Our 
reviewer says that the home health aide services are not reasonable and necessary. 
 
 
 
 
 
Our physician reviewer found the records do not show that skilled therapy is needed to effectively provide 
treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a 
maintenance program to maintain the patient's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 60 days of home health aide services for nursing evaluation and treatment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 22, 2019. 
 
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 billed are not supported by the documentation. 
 
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 August 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on May 3, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because you 
went to an in-network provider. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 20% 
coinsurance for DME and related supplies.  
 
You received DME on May 3, 2020. The allowed amount is $100.79 and 20% of that is $20.16.  
 
You have been asked to pay the total coinsurance amount of $20.16 for DME. DME falls within the DME and 
related supplies 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 coinsurance for DME provided on May 3, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you no longer have care needs that require skilled professionals at a 
recovery facility. 
 
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 your condition does not meet 
Medicare criteria for continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cardiovascular risk assessment panel provided on May 13, 2020.You asked the Plan to pay forthe cardiovascular risk assessment panel. 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.Thecardiovascular risk assessment panel 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 forthe cardiovascular risk assessment panel provided on May 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the enrollee. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that these services do not need to be handled as 
inpatient only. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. There is no documentation provided indicating medical necessity for an inpatient admission for the 
procedure. Specifically, the surgery code given hasn?t been or is no longer on the Medicare Inpatient Only List. 
Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health services provided from August 21, 
2018 to August 23, 2018. 
 
You asked the Plan to pay for inpatient services. The Plan denied your request. The Plan says a less restrictive 
level of care was appropriate. 
 
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 inpatient services. Our physician reviewer 
found that active treatment was not taking place. The services were not reasonably expected to improve the 
enrollee's condition, or for the purpose of diagnosis. There is no individualized treatment found, however, the 
entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based 
upon review the records, the enrollee was not shown to be a danger to herself or others, auditory or visual 
hallucinations. She is noted to be cooperative and compliant with treatment while not showing any acute threat 
to safety. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pay for inpatient mental health services provided from August 21, 2018 to August 23, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (Q9966, J7320, 20610, 77002) provided on 
November 13, 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 use 
of codes Q9966, J7320, and 20610 is not supported by the records provided. Our coding reviewer found that 
the operative report does not include the date that the billed services were performed. Therefore, these codes 
cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes Q9966, J7320, and 20610, have not been met.  
 
 
 
Medicare rules also say that the CPT Manual are identified as 'add-on' codes which describe a service that can 
only be reported in addition to a primary procedure. CPT code 77002 is an add-on code. As the primary 
procedure code 20610 is not supported by the records provided, the add-on code is not payable. Therefore, we 
decided that the Plan does not have to pay for the services (Q9966, J7320, 20610, 77002) provided on 
November 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on June 5, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you had a low dose CT scan. You say 
that you think this was processed incorrectly. 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 $200 
copayment for outpatient diagnostic tests/CT scans.  
 
You have been asked to pay a $200 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests/CT scans 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 a CT scan provided by a 
participating provider on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation, complete series of intraoral x-rays, and panoramic x-ray provided on February 24, 2020.You asked the Plan to pay forthe comprehensive oral evaluation, complete series of intraoral x-rays, and panoramic x-ray. You say that you found a new provider and received these services.The Plan denied your request. The Plan says your benefit limits for these services had been exceeded.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, oral exams are limited to 1 every 6 months. The record shows that you received a comprehensive oral evaluation on September 11, 2019, and your oral exams benefit had been exhausted. The contract also says that complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330) are limited to 1 per 36 months (either D0210, D0277, or D0330). The record shows that you received a complete series of intraoral x-rays on September 11, 2019, and your complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330) benefits have been exhausted.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation, complete series of intraoral x-rays, and panoramic x-ray provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the qualified physical therapist assistant services provided on , the direct skilled nursing service, and the qualified physical therapist services provided. 
 
You asked the Plan to pay for the qualified physical therapist assistant services, the direct skilled nursing 
services, and the qualified physical therapist 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 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. 
 
We find that the services billed are not supported in the medical record. Specifically, these claims are not 
payable with the type of bill code that was submitted. Based on this information, we decided that Medicare 
rules for coverage of the qualified physical therapist assistant services, the direct skilled nursing services, and 
the qualified physical therapist services have not been met. Therefore, we decided that the Plan does not have 
to pay for the qualified physical therapist assistant services provided, the direct skilled nursing services provided, 
and the qualified physical therapist services provided.
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 the additional trips. You say that you feel that transportation to get cancer 
treatment is not a luxury for you but is medically necessary. You say that transportation to follow-up treatment 
should be covered as it is a matter of life and death. The Plan denied your request. The Plan says your benefit 
only covers 24 one-way trips. You have received 24 trips and no further coverage is offered by the Plan. 
 
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 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. Although this may 
be necessary, there is no provision in your contract which would require the Plan to cover more than 24 trips. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ostomy deodorant (A4394), ostomy 
skin barriers (A4414), adhesive remover wipes (A4456), ostomy pouches (A5054), and the skin barrier wipes 
or swabs (A5120) provided on January 7, 2020 and April 20, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
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 prosthetic devices and medical supplies.  
 
You have been asked to pay $370.74 ($926.88 Plan allowed amount x 20% coinsurance=$185.37 x 2 days) for 
the prosthetic devices and medical supplies provided. 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 coinsurance for 
the ostomy deodorant (A4394), ostomy skin barriers (A4414), adhesive remover wipes (A4456), ostomy 
pouches (A5054), and the skin barrier wipes or swabs (A5120) provided on January 7, 2020 and April 20, 
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 enrollee needs an acute rehab setting for 
aggressive therapy. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
because they do not have intensive therapy needs given their current level of function. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. Our reviewer found that the enrollee continues to have 
a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, 
the documentation does not support that he would meet criteria for admission to an acute inpatient 
rehabilitation facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain their functional status. Our physician reviewer also found that there is no 
documentation to support the need for admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.