Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
requested services exceed the medically necessary amount. 
 
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.  
 
The file shows that 18 physical therapy and 9 skilled nursing visits were requested. The Plan has agreed to pre-
approve 12 physical therapy and 6 nursing visits. We asked our physician reviewer to carefully review the case 
file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-
approve additional services. Our physician reviewer found that you have been receiving home physical therapy 
due to increased weakness and home skilled nursing visits with at least 2 episodes of care. Your prior level of 
functioning was independent with activities of daily living, and functional mobility using a walker. You 
continue to be independent with transfers, toileting and ambulation with a walker. The most recent 
documentation indicates that you have been medically stable. There is no indication that you had any recent 
medication changes or hospitalizations. The documentation does not support that you require the requested 
additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. 
You have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. You have improved with skilled care, and should be independent with a home exercise 
program. Therefore, the additional services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 31, 2020, by an 
OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that these medically necessary services 
were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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 August 31, 2020, 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) imaging services to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON CT scan. You say that this imaging is medically necessary and 
was requested by the physician who has been treating the enrollee. The Plan denied your request. The Plan says 
the facility from which this imaging is requested is OON. There are network facilities which can provide the 
required imaging in a reasonable time frame. 
 
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 computed tomography (CT) imaging services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(95940) intraoperative neuromonitoring (95938) electroencephalogram (EEG) procedures (95955) provided 
May 7, 2019. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the plan's lack of receipt may have 
been due to an address change, electronic transmission failure or other internal issue. However, it is your 
position that you met your timely filing obligation. The Plan denied your request. The Plan says the time limit 
for filing has expired. 
 
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 neuromonitoring services was not filed until July 7, 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 continuous intraoperative neurophysiology monitoring (95940) 
intraoperative neuromonitoring (95938) electroencephalogram (EEG) procedures (95955) provided May 7, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee's further care could occur safely in a skilled nursing 
facility. 
 
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 LTACH care is not considered medically reasonable and necessary in this case. The patient 
was treated at am acute care hospital (ACH) for CoViD-19. She was then transferred to a LTACH. At the time 
of transfer, the enrollee was not intubated/ventilated. There is no evidence that the enrollee required services 
that were not available at the ACH. As LTACHs and ACHs are licensed to provide the same level of care, there 
was no advantage in transferring the enrollee to the LTACH. The enrollee could have remained at the ACH 
until such time no acute services were required. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630), the unspecified preventive procedure (D1999), the non-autogenous connective tissue graft 
(D4275), the free soft tissue graft procedure (D4277), and the scaling and root planing (D4342) rendered by the 
out of network (OON) provider on August 17, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 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 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 the drugs or medicaments dispensed in the office for home use (D9630), the 
unspecified preventive procedure (D1999), the non-autogenous connective tissue graft (D4275), the free soft 
tissue graft procedure (D4277), and the scaling and root planing (D4342) rendered by the out of network 
(OON) provider on August 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee continues with mid-back pain. The 
Plan denied your request. The Plan says there are contracted providers available for this service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance imaging (MRI) services to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to reimburse for the services provided to the enrollee on January 4, 2020, and 
January 5, 2020. 
 
You asked the Plan to reimburse for the services. The Plan denied your request. The Plan says that the claim is 
not in English. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not submitted documentation adequately supporting its denial. The 
Plan does not appear to have forwarded all documentation regarding the service in question and the denial of 
them. Without supporting documentation, the Plan's denial cannot be substantiated. The plan must provide full 
reimbursement of the $7,847 paid to the hospital by the enrollee. Therefore, we decided that the Plan has to 
reimburse for the services provided to the enrollee on January 4, 2020, and January 5, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided by a 
participating provider on May 31, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are on a fixed income 
and you cannot afford this. 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 ambulance services.  
 
You have been asked to pay a $200 copayment for ambulance services. Since ambulance services were 
provided, the correct copayment has been applied. Ambulance services fall within the ambulance services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided by 
a participating provider on May 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen/pelvis 
rendered on July 24, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 74176 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 74176 and 74177. Code 74176 is a column II code with a 
modifier indicator of 1 when billed with column I code 74177. Code 74176 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan of the abdomen/pelvis rendered on July 24, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the neck (70490). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says that the CT scan cannot be approved without results from the previous scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan. Our reviewer says that the 
requested CT scan is medically necessary. Our physician reviewer found the enrollee's clinical presentation has 
changed such that this scan should no longer be considered a follow up scan. CT imaging is medically 
appropriate. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a Computed Tomography (CT) scan of the neck (70490).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on August 5, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges and feel that 
they are too high. 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 August 5, 2020. The allowed amount is $2,114.48 and 20% of that is $422.90.  
 
You have been asked to pay the total coinsurance amount of $422.90 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 durable medical 
equipment (DME) provided on August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 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 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 the medical services provided to the enrollee by an out-of-network provider 
on April 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services provided 
on May 15, 2020. 
 
You asked the Plan to waive the coinsurance for the outpatient hospital services. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received outpatient surgery in an outpatient hospital facility 
on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your 
contract with the Plan. 
 
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 each Medicare-covered outpatient hospital visit and hospital outpatient surgical facility.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient 
surgical services in an outpatient hospital facility on May 15, 2020. You have been asked to pay a 20% 
coinsurance for the outpatient hospital services, totaling $2400.82. The outpatient hospital services fall within 
the Outpatient surgery 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 the 
outpatient hospital services provided on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment received on March 5, 2020 and March 
6, 2020. 
 
You asked the Plan to pay for the oxygen equipment. You say that you disagree with the plan's denial. The Plan 
denied your request. The Plan says the items received are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The rules also say that only rented oxygen and oxygen equipment are 
eligible for coverage. 
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. In addition, payment is not made for purchases 
of oxygen and oxygen equipment. Only rented oxygen and oxygen equipment are eligible for coverage. 
Therefore, we decided that the Plan does not have to pay for the oxygen equipment received on March 5, 2020 
and March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CYP panel rendered on July 10, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are 
non-covered. 
 
The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code. 
Furthermore, this testing is not covered by Medicare. Therefore, we decided that the Plan does not have to pay 
for the CYP panel rendered on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out-of-network dental services (D0120, D0220, D0274, 
D0230) provided on February 19, 2020. 
 
You asked the Plan to pay for out-of-network dental services. You say that this provider was in-network in the 
past. The Plan denied your request. The Plan says this provider is not in-network. 
 
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, out-of-network services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for out-of-network 
dental services (D0120, D0220, D0274, D0230) provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
only services that are covered for an out-of-network provider are emergency, urgently needed care, and out of 
network dialysis or if there is not a network provider able to provide care. This request is not related to 
emergency or urgent care, and there are in-network providers within 10 miles of your home that can treat your 
condition. 
 
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 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 
physician's services to be provided by the out-of-network provider.