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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
June 3, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care 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 a 
covered benefit. 
 
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 care services 
provided on June 3, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on October 4, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you should not have to pay the copay 
because the provider submitted the wrong billing code. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 4, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 4, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the laboratory services rendered on June 1, 
2020 and June 15, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you were mandated to have 
testing by the governor. The Plan denied your request. The Plan says the copayments were 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 a $12 
copayment for in-network Medicare-covered lab tests.  
 
Review of the file shows that you received laboratory services on June 1, 2020 and June 15, 2020. You have 
been asked to pay a $12 copayment per day for these services, for a total of $24. These services fall within the 
in-network Medicare-covered lab tests 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 copayments for 
the laboratory services rendered on June 1, 2020 and June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 3, 2020. 
 
You asked the Plan to pay for the office visit. 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 an office visit provided on June 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Positron Emission Tomography (PET) scan (78815) provided May 22, 2020.You asked the Plan to pay forthe PET scan. You say that the service was medically necessary.The Plan denied your request. The Plan says the claim did not include an appropriate diagnosis code.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 78815 is not supported in the medical record. Specifically, C50.911 (Malignant neoplasm of unspecified site of right female breast) is not listed as an appropriate diagnosis for this CPT code. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met.Therefore, we decided that the Plan does not have to pay fora Positron Emission Tomography (PET) scan (78815) provided May 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance transport (A0428, A0425) provided December 
20, 2019. 
 
You asked the Plan to pay for the ambulance transport. You say that the transport was medically necessary. 
The Plan denied your request. The Plan says transport from a patient's home to an outpatient facility and back 
is not a covered transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. An outpatient facility such as a doctor's office is not a 
covered destination.  
 
 
The services you have asked the Plan to pay for are ambulance transport services to an outpatient facility. 
Therefore, we decided that the Plan does not have to pay for an ambulance transport (A0428, A0425) provided 
December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction study (95913) needle electromyography 
(95886) and needle electromyography (95886-59) provided December 4, 2019. 
 
You asked the Plan to pay for the nerve conduction study. You say that please accept the attached additional 
medical records along with the WOL form to review this charge and kindly reprocess this claim for a payment. 
The Plan denied your request. The Plan says the services are not supported in the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
 
 
In this case, we find that CPT code 95913, 95886 and 95886-59 is not supported in the medical record. 
Specifically, 95913 was not documented in the medical records submitted for review. The technical report did 
not include documentation of nerve conduction studies; for 13 or more studies. 95886 and 95886-59 are not 
substantiated by the clinical documentation in the technical report submitted for review. The technical report 
did not include documentation of a complete needle electromyography, per each extremity with related 
paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; for five or 
more muscles studied, innervated by three or more nerves or four or more spinal level. Based on this 
information, we decided that Medicare rules for coverage of the nerve conduction study have not been met. 
Therefore, we decided that the Plan does not have to pay for nerve conduction study (95913) needle 
electromyography (95886) and needle electromyography (95886-59) provided December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 31, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
1, 2020, to April 27, 2020. 
 
You asked the Plan to pay for home health services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, these 
services were billed with an invalid Type of Bill (TOB) code. Therefore, we decided that the Plan does not 
have to pay for the home health services provided to the enrollee from April 1, 2020, to April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
May 29, 2020. 
 
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 the enrollee 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 to the enrollee on May 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 2, 2020, through June 7, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you believe you were overcharged for services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on June 2, 2020, and discharged on June 7, 2020. You were asked to pay a $372 copayment per day from June 2, 2020, through June 6, 2020, days 1-5 of your inpatient hospital care. You were discharged on June 7, 2020, and there was no copayment charge for the day of discharge. Per your contract there is a $372 copayment per day required for days 1-5. 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 inpatient hospital care provided from June 2, 2020, through June 7, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive this copayment.  
 
You asked the Plan to waive your emergency room copayment. You say that you do not believe this copayment 
is correct. The Plan denied your request. The Plan says this copayment is a contractual obligation for 
emergency room services. 
 
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 $90 
copayment for emergency room services.  
 
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 waive this copayment.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on February 12, 2020. 
 
You asked the Plan to pay for the psychotherapy 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 psychotherapy services provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dermatology service provided. 
 
You asked the Plan to waive the copayment for specialist service. You say that this procedure should have been 
done at your first visit with this doctor, so you should not be charged another $25 copayment. The Plan denied 
your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $25 
copayment for in-network dermatology visit.  
 
You have been asked to pay $25 copayment for specialist service. Specialist service falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 dermatology service provided.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 9, 2019, to June 
11, 2019. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
that the inpatient care was not medically necessary. 
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee was admitted on June 9, 2019, with right flank pain and nausea and 
placed on observational status for pain control. The enrollee had an MRI revealing no acute fracture or lesion. 
Member did not have any bowel or bladder problems, progressive neurological deficits or concern for 
impingement. Member did not require surgery and did not have any other serious conditions documented. The 
record showed 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 the acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from June 9, 2019, to June 11, 2019.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B drugs you received on April 21, 
2020. 
 
You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says you are responsible 
for the cost share. 
 
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 Medicare Part B prescription drugs.  
 
Review of the file shows that you were provided Part B drugs on April 21, 2020. You have been asked to pay a 
20% coinsurance for the drugs, totaling $616.76. The drugs fall within the Medicare Part B prescription drugs 
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 Part B drugs you received 
on April 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by Hardin Co Ambulance 
Service on April 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 8, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by Hardin Co 
Ambulance Service on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forurine infectious agent DNA/RNA testing with antibiotic resistance testing provided on March 9, 2020.You asked the Planto pay forthe urine testing. You say that this testing was medically necessary and should be paid.The Plandenied your request. The Plansaysthe reported POS code is 81 which is not appropriate for samples taken in the office setting and sent to an independent lab.The Plan must follow Medicare rules. Medicare rules say that the POS code reported for lab testing must match the setting in which the sample was taken.In this case, the documentation does not support that the sample was taken by the lab to support the POS code 81.Therefore, we decided that the Plandoes not haveto pay forurine infectious agent DNA/RNA testing with antibiotic resistance testing provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the assistant surgeon services provided on December 26, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were 
provided by a nurse. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record shows that the provider of the surgical assistant service is a nurse practitioner (NP). 
Medicare makes payment for surgical assistant services provided by this type of practitioner. Therefore, we 
decided that the Plan has to pay for the assistant surgeon services provided on December 26, 2019.  
 
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 pay for the acute inpatient hospital care provided from April 28, 
2020, through May 2, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was necessary. The Plan 
denied your request. The Plan says the stay was  not necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found at the time of the admission, the clinical presentation including no reported 
symptoms anymore and vitals and blood work stable or normal, additional evaluation and treatment would not 
have taken more than two midnights in the hospital. The additional antibiotics and tests could have been 
performed under observation status or as outpatient based on the provided notes. 

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 pay for the acute inpatient hospital care provided from April 28, 2020, through May 2, 
2020.