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

 
We decided that the Plan does not have to waive the deductible for the outpatient visit you had on May 5, 2020. 
 
You asked the Plan to waive the deductible for the outpatient hospital facility services. You say that you do not 
agree with the policy of having the clinic bill when patients walk into the clinic. The Plan denied your request. 
The Plan says you were charged this deductible appropriately. 
 
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 a $290 deductible that applies to outpatient hospital and specialist 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $290 
deductible for the type of services you received. This cost sharing is a contractual obligation that had not been 
met at the time the outpatient hospital facility services was received on May 5, 2020. Therefore, we decided 
that the Plan does not have to waive the deductible for the outpatient visit you had on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided by a 
participating facility on June 4, 2020. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you thought all copayments 
were waived during Covid-19. 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 $25 
copayment for urgently needed services/other providers.  
 
You have been asked to pay a $25 copayment for urgent care services. Urgent care services were provided; 
therefore, the correct copayment has been applied. Urgent care services fall within the urgently needed 
services/other providers 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 urgent care 
services provided a participating facility on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the Zoll LifeVest automatic external 
defibrillator rental provided on August 16, 2019. 
 
You asked the Plan to waive the charges for the LifeVest rental. You say that you do not feel that you should 
have to pay for a cost that you were not warned about. The Plan denied your request. The Plan says your 
contract covers durable medical equipment with a 20% coinsurance. You are being asked to pay 20% of the 
allowed amount for this device. 
 
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 durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the LifeVest rental. The LifeVest rental 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 waive the charges for the Zoll 
LifeVest automatic external defibrillator rental provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Transitional Care Management services (99496) provided on 
November 20, 2019. 
 
You asked the Plan to pay for the Transitional Care Management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says Transitional Care 
Management services are performed after a patient's discharge and must be billed to the patient's home, a 
domiciliary center, rest home or nursing home or an assisted living facility and Skilled nursing facilities do not 
apply. 
 
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 99496 is  Transitional Care Management Services with 
the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of high complexity during the service 
period Face-to-face visit, within 7 calendar days of discharge. 
 
We find that CPT code 99496 is not supported in the record. Specifically, this claim was billed with place of 
service code 31 for a Skilled Nursing Facility. Transitional Care Management services must be billed to the 
member's home and Skilled Nursing Facilities do not apply.  Based on this information, we decided that 
Medicare rules for coverage of the Transitional Care Management services have not been met. Therefore, we 
decided that the Plan does not have to pay for Transitional Care Management services (99496) provided on 
November 20, 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 based on review of the 
medical records, the enrollee does not meet criteria for an IRF admission based on lack of medical and nursing 
needs. The enrollee is generally medically stable. There is no evidence of new or acute medical issues that 
require monitoring by an inpatient rehab physician three times a week. The documentation does not support 
that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to 
rehab care. She needs physical therapy and occupational therapy but not necessarily 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit and electrocardiogram. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider is 
not a network provider and the services were not urgent, emergent or approved in advance. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99203) rendered by the out ofnetwork (OON) provider on June 2, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was rendered by an outof 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approvethe service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay forthe office visit (99203) rendered by the out of network (OON) provider on June 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay from March 13, 2020, to March 17, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you disagree with the charges because you did not receive a private room.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 a $450 copayment for each day for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from March 13, 2020 to March 17, 2020. Therefore, you are responsible to pay a $450 copayment for days 1-4 (March 13, 2020, to March 26, 2020). $450 (copayment) x 4 (inpatient days) = $1,800. You have been asked to pay the total copayment amount of $1,800 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 foran inpatient hospital stay from March 13, 2020, to March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on October 10, 2019. 
 
You asked the Plan to pay for the resin-based composite. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on 
April 28, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility visit. 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; therefore, payment has been correctly denied. 
 
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 subsequent nursing facility visit (99309) 
provided on April 28, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic x-ray (D0330) provided on June 16, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were never advised by a plan representative 
that you could not get another x-ray. You also say that you thought the x-rays would be covered. The Plan 
denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan 
also says 1 panoramic x-ray is covered every 3 plan years. 
 
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 and comprehensive oral evaluations 
and panoramic x-rays are listed as covered, the frequency limit of once every 3 plan years has been exceeded. 
The record shows that the Plan paid for both of these services that you received on August 15, 2019. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic x-ray (D0330) provided on June 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xtandi 40mg capsules. 
 
You asked the Plan to pre-approve the Xtandi capsules. You say that this medication is necessary and should be 
approved. The Plan denied your request. The Plan says this drug only comes in an oral non-self-administered 
form which means it cannot be covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 
Although some oral anti-cancer drugs may be covered, this drug is not eligible for Part B coverage because it 
does not have an injectable version. Therefore, we decided that the Plan does not have to pre-approve Xtandi 
40mg capsules.  
 
Benefits for the Xtandi capsules may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with diabetes who 
had a urinary tract infection and pneumonia. From a nursing perspective, the enrollee received oral and inhaled 
medications and insulin. The enrollee had stable vital signs. She was treated with daily IV antibiotics for a 14-
day course. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The 
enrollee was at a stand by assist/supervision level with functional mobility including gait to 500 feet with a 
cane.   
 
There are identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis.  This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy procedure. 
 
You asked the Plan to pre-approve a panniculectomy procedure. You say that the requested panniculectomy is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested panniculectomy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a panniculectomy procedure. Our 
reviewer says that the enrollee does not meet criteria for the requested panniculectomy. Our physician reviewer 
found the enrollee underwent a Roux-en-Y gastric bypass on 3/5/19, and had lost 125 pounds as of 8/17/20. It 
has not been at least 24 months since the enrollee's bariatric surgery, and it remains to be demonstrated that the 
weight will be stable for at least six months and that infection and inflammation will continue after that time. 
The requested panniculectomy is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a panniculectomy procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a panniculectomy procedure.
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 based on review of the 
medical records, the enrollee does not meet criteria for an IRF admission based on lack of medical and nursing 
needs. The enrollee is generally medically stable. There is no evidence of medical issues that require 
monitoring by an inpatient rehab physician three times a week. The documentation does not support that there 
is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. 
He needs physical therapy and occupational therapy but not necessarily 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery for a loculated pleural effusion.  The enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires services that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can then be transferred/dischargedto a lower level of care for any ongoing long term care needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is 
with back pain. The requested Vertiflex device is experimental. More research is needed to show safety and 
efficacy. The requested device is not medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.