Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on July 24, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be 
submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on July 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on July 8, 2020, and July 
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 July 8, 2020, and July 27, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on April 20, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 90 remains not 
supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when 
the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a 
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11.  Also, the laboratory results submitted indicate the 
specimen was collected on April 20, 2020 and received by the lab on April 22, 2020.  It is noted multiple 
attempts were made to obtain additional information from the provider 
 
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 POS code reported on the claim 
is causing errors preventing payment. Medicare rules for coverage of this testing have not been met. Therefore, 
we decided that the Plan does not have to pay for drug testing provided to the enrollee on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on June 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 you by an out-of-network provider on June 
9, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation in the case file does not 
support that the enrollee requires skilled nursing services. The documentation in the case file does not support 
that the enrollee requires skilled therapy services. This enrollee does not require the necessary services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered from June 24, 2020 to June 
25, 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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
provider submitted a claim for procedure codes 97110 (therapeutic exercises) and G0283 (electrical 
stimulation). Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered 
from June 24, 2020 to June 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on 
December 5, 2019. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you believe the 
copayment should be waived. The Plan denied your request. The Plan says you were charged this copayment 
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 $125 
copayment for ambulance services.  
 
You have been asked to pay a $125 copayment for the ambulance services. 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 you received on December 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the aortography services you received at an 
outpatient hospital facility on March 11, 2020. 
 
You asked the Plan to waive the copayment for the aortography services. You say that your doctors ordered 
this test and you don't understand why the Plan didn't pay for it. The Plan denied your request. The Plan says it 
paid for the test but the remaining balance represents your cost sharing.  The Plan says you were charged this 
copayment 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 $100 
copayment for diagnostic procedures and tests performed at an outpatient hospital facility.  
 
You have been asked to pay a $100 copayment for the aortography services. The aortography services fall 
within the diagnostic procedures and tests performed at an outpatient hospital facility 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 the aortography services you received at an outpatient 
hospital facility on March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on April 23, 2020 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
the enrollee must receive care from in-network providers with the exception of emergency or urgent care, 
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network 
provider, which requires prior authorization from the plan.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
diagnostic radiology 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 diagnostic radiology services provided on April 
23, 2020
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on February 3, 2020.  
 
You asked the Plan to pay for lab services provided on February 3, 2020. . You say that these services should 
be covered by the Plan. The Plan denied your request. The Plan says that the claim was submitted with 
incorrect modifiers and therefore cannot be paid. 
 
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 is not clear on identifying who the ordering provider 
was for these lab services. It appears your physician ordered these services. You would not be responsible for 
how this claim is billed or which lab your specimen was sent to. The Plan has not provided sufficient 
information to substantiate its denial. Therefore, we decided that the Plan has to pay for lab services provided 
on February 3, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer to a lower level of care may be considered when treatment has 
completed. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on February 20, 2020. 
 
You asked the Plan to pay for the occupational therapy. The Plan denied your request. The Plan says it is 
important to know which providers are part of our network because, with limited exceptions, while you are a 
member of our plan you must use network providers to get your medical care and services. The only exceptions 
are emergencies, urgently needed services when the network is not available (generally, when you are out of 
the area), out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers. 
 
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 
occupational therapy. 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 occupational therapy provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on August 12, 
2019.  
 
You asked the Plan to pay for out of network providers. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide the 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 out of network physician 
services provided on August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia services (01992) provided June 30, 2020. 
 
You asked the Plan to pre-approve the anesthesia services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that neither conscious sedation nor Monitored Anesthesia 
Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not 
routinely reimbursable. 
 
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 anesthesia services. Our reviewer 
says that the monitored anesthesia was not medically necessary. Our physician reviewer found medial branch 
blocks are typically performed in an ambulatory setting without monitored anesthesia care. The enrollee's 
history does not support the use of monitored anesthesia care. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve anesthesia services (01992) provided June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on August 26, 
2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the lab tests were 
necessary for your annual physical. You say that you shouldn't have to pay the copayment. The Plan denied 
your request. The Plan says the copayment applied 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 $10 for 
Medicare-covered laboratory tests.  
 
You have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall within 
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic 
tests are considered a separate service. 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 laboratory 
services provided on August 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent 
leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, 
ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when 
performed (CPT Code 33274). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the records show an approval for the same service or one like it on file for the member, 
and it is still in effect. The Plan states the records do not show the results of this service and do not show if 
there are plans for the service. The Plan states the approved service may show the doctor what they needed to 
see in order to treat the member's condition and further services cannot be approved without knowing the 
outcome of the prior approval. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. There is no documentation 
supporting the member is participating in an approved CED study. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, 
including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and 
device evaluation (eg, interrogation or programming), when performed (CPT Code 33274).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided August 15, 2020 to August 
16, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the claim should be paid. The Plan 
denied your request. The Plan says a corrected claim is required. 
 
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  is not supported in the medical record. Specifically, it was determined that the inpatient 
services were medically necessary, however the claim was submitted with Type of Bill 110 which is invalid for 
this service. A corrected claim must be submitted to the plan. Based on this information, we decided that 
Medicare rules for coverage of the inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital care provided August 15, 2020 to August 16, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you had 
on January 6, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that you should be paying nothing 
because this was not the emergency room- it was urgent care. The Plan denied your request. The Plan says you 
were charged this copayment 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 $50 
copayment for emergency room visits.  
 
You have been asked to pay a $50 copayment for the ER services. Billing records show that these services 
were billed as emergency room services. In addition, medical records from this date of service show that these 
were emergency room services. 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 the emergency room (ER) 
services you had on January 6, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found there are no required skilled nursing services identified. The documentation supports that enrollee in this 
case may benefit from skilled therapy services, but daily therapy services not reasonable or necessary. This 
enrollee does not require the necessary services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve 
SNF care.