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

 
We decided that the Plan does not have to pay for advance care planning (99497) provided on October 20, 
2019 through October 21, 2019. 
 
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 99497 
 is advance care planning including the explanation and discussion of advance directives such as standard 
forms (with completion of such forms, when performed), by the physician or other qualified health care 
professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. 
 
We find that CPT code 99497 
 is not supported in the record. Specifically, the record does not indicate that at least 30 minutes of advance 
care planning services were rendered on the billed date of service. Based on this information, we decided that 
Medicare rules for coverage of the advance care planning have not been met. Therefore, we decided that the 
Plan does not have to pay for advance care planning (99497) provided on October 20, 2019 through October 
21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology services provided on March 19, 2020. 
 
You asked the Plan to pay for the cytopathology services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88112 is not supported in the medical record. Specifically, this service was billed twice 
for the same date of service. Once was billed with modifier 26 (professional component) and once without a 
modifier (global service). This code was already processed and paid with the no modifier. This service can only 
be paid once. Based on this information, we decided that Medicare rules for coverage of the cytopathology 
services have not been met. Therefore, we decided that the Plan does not have to pay for the cytopathology 
services provided on March 19, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 1, 2020 
to March 18, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you cannot afford the charges. 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 $20 
copayment per day for days 1-20 and a $60 copayment per day for days 21-44 for SNF care.  
 
You have been asked to pay $895, which is less than the total copayment amount for a SNF stay. A SNF stay 
falls within the SNF 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 for a SNF stay 
provided from February 1, 2020 to March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustable bed base, firm queen mattress and mattress 
protector purchased on January 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the bed and mattress. You say that you are appealing the decision to not pay 
because if the plan had approved the hospital bed the first time this bed would not be at your house and you are 
not able to give it back. The Plan denied your request. The Plan says the furniture retailer is not a DME 
supplier and does not accept Medicare assignment. The bed purchased is an ordinary bed with an adjustable 
mattress and not a hospital bed. 
 
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 adjustable bed base, firm queen mattress and 
mattress protector purchased on January 29, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 23, 2019. 
 
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 testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on August 30, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for optometry services provided on July 11, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for optometry services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services could have been provided in-network. The Plan says that 
prior authorization was not obtained. 
 
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 optometry services provided on July 11, 2019 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telemedicine outpatient specialist office 
visit provided a participating provider on April 8, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you only talked to the 
doctor for three minutes. 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 $40 
copayment for physician/practitioner services/in-network/Select.  
 
You have been asked to pay a $40 copayment for a specialist office visit. Since specialist services were 
provided, the correct copayment has been applied. A specialist office visit falls within the 
physician/practitioner services/in-network/Select benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a telemedicine outpatient specialist office visit provided a participating provider on April 8, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the chest (71250). 
 
You asked the Plan to pay for the CT scan. You say that the claim was not correctly processed. The Plan denied 
your request. The Plan says the claim was processed correctly as received. 
 
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 71250 is not supported in the medical record. Specifically, the record shows the plan 
processed the claim as submitted following rules for IHS providers outlined in the Medicare Claims Processing 
Manual Chapter 19/100.5.1 - A/B MAC (A) - Outpatient - Medicare Part B - Claims Processing. No corrected 
claim was submitted to the plan. Based on this information, we decided that Medicare rules for coverage of the 
CT scan have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography 
(CT) of the chest (71250).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the occupational therapy visit provided on 
August 26, 2019. 
 
You asked the Plan to waive the copayment for the occupational therapy visit. You say that you do not owe the 
copayment. You say an old account was incorrectly billed. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing 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 $40 
copayment for each in-network Medicare-covered therapy visit.  
 
You have been asked to pay a $40 copayment for the occupational therapy visit. The occupational therapy visit 
falls within the "Outpatient rehabilitation 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 the occupational therapy visit provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym membership fee purchased January 15, 2019. 
 
You asked the Plan to pay for the gym membership fee. You say that the documents provided should show 
proof of the monthly payments paid for your gym membership. The Plan denied your request. The Plan says 
the documentation (bank statement for the first month and last month)  provided shows that the enrollee only 
paid $29.99. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
only will reimburse for the amounts identified in the receipts, up to the benefit limit. 
 
The Plan's rules for coverage of gym benefits have not been met because the bank statements provided shows 
that the enrollee only paid $29.99. Additional information or receipts showing payment of the remaining $120 
was not provided and therefore not verified. Therefore, we decided that the Plan does not have to pay for the 
gym membership fee purchased January 15, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says you have reached the 100-day benefit limit. Therefore, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 19, 2020 to 
August 16, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on October 2, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. 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. 
 
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 
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 skilled nursing services provided on October 2, 
2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
21, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
charges. 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 $260 
copayment for ambulance services.  
 
You have been asked to pay a $260 copayment for ambulance services. 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 on February 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the enrollee has no acute symptoms 
requiring 24 hour inpatient care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee in this case. The enrollee did not appear to require inpatient mental health treatment beyond August 6, 
2020, as the enrollee was not a danger to herself or others, there were no auditory hallucinations or visual 
hallucinations while being cooperative with treatment. She needed partial assistance with activities of daily 
living but had independent ambulation. It did not appear that active treatment was taking place beyond the date 
in question. It did not appear that the services were reasonably expected to improve the patient?s condition or 
for the purpose of diagnosis beyond the date in question. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan benefits say this medication falls under Part D coverage, but the enrollee has 
not Part D pharmacy benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rocklatan for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan eye drops. 
 
You asked the Plan to pre-approve the eye drops. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription 
drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan eye drops.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that the enrollee needs a scooter to transport 
herself to the grocery store and pharmacy. The Plan denied your request. The Plan says any power operated 
vehicle for use outside the hope will be denied as non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (99245) for a second opinion to be 
rendered by the out of network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says an in-network provider is available to render 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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a 
consultation (99245) for a second opinion to be rendered by the out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services coded 95886 provided 
on December 17, 2019. 
 
You asked the Plan to pay for the needle electromyography services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan 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 95886 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate that a needle was utilized to perform the billed service. The documentation submitted 
did not include documentation of needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 
studied, innervated by three or more nerves or four or more spinal levels; therefore, the billed service cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of the needle 
electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the 
needle electromyography services coded 95886 provided on December 17, 2019.