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

 
We decided that the Plan does not have to waive the copayment for a doctor's office visit (99212) on June 9, 
2020. 
 
You asked the Plan to waive the copayment for a doctor's office visit. You say that you were never informed 
that this visit was anything but your annual wellness exam. The Plan denied your request. The Plan says the 
correct copayment was 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 $10 
copayment for each primary care office visit.  
 
You have been asked to pay a $10 copayment for a doctor's office visit. The case record documents that you 
received services and care during this visit beyond the scope of the annual wellness visit. A doctor's office visit 
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 a doctor's office visit (99212) on June 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Occlusal Guard (D9944).You asked the Plan to pre-approve an Occlusal Guard. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested Occlusal Guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an Occlusal Guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat facet joint injection. 
 
You asked the Plan to pre-approve the repeat injection. You say that you are in pain and cannot sit up straight 
or walk well. The Plan denied your request. The Plan says the requested injections are not medically necessary 
because the records show you did not have at least 80% relief of your primary back pain. 
 
The Plan follows Medicare rules. Medicare rules say that a confirmatory diagnostic facet joint injection is 
covered only if the first injection provided at least 80% pain relief.  
 
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 repeat injection. Our reviewer says 
that a second facet joint injection is not considered reasonable and necessary in this case. Our physician 
reviewer found the LCD requires 80% or greater pain relief documented from each set of diagnostic 
injections.  Since only 60% pain relief was achieved, the result should be interpreted as negative. Therefore, a 
second set of blocks is not indicated, and the request is deemed not medically reasonable or 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 the repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat facet joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested RFA is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
RFA. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation. Our reviewer 
says that the enrollee does not meet criteria for the requested RFA. Our physician reviewer found the enrollee 
is with chronic back pain. Criteria for RFA injection are not met. There is no documentation of degree of pain 
relief with previous injection therapy. More information is needed to justify RFA injection at this time for 
chronic lower back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is unable to go home at the 
current level and further care is needed. The enrollee would greatly benefit from more therapy time in a 
subacute setting so that he can live more independently in the future. The Plan denied your request. The Plan 
says the enrollee's needs are custodial and can be provided at a lower level of care. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 67-year-old male 
with a pituitary adenoma who was admitted to the hospital for planned resection on 8/13/2020. The surgery 
was complicated by a left internal capsule infarct with resulting pan-hypopituitarism and a dense right-sided 
hemiplegia. He suffered from respiratory failure that eventually required a tracheostomy and feeding tube 
 
 
placement. He was discharged to an inpatient rehabilitation facility on 9/18/2020. He has stabilized medically 
and no longer receives nutrition via a feeding tube and was decannulated.  
 
The enrollee has stabilized medically and is ready for discharge from the inpatient rehab facility due to a 
plateau in improvement. He does not require skilled nursing and/or skilled therapy services on a daily basis. He 
is medically stable and can receive further rehab services at a lower level of care. Although further rehab 
services would be appropriate to improve function, as a practical matter, the daily skilled services can be 
provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parenteral 
medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without 
any acute exacerbations of chronic medical problems. His physical function is at or near his new baseline and 
he can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says care must be received from a network provider. 
 
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 
a referral to an out-of-network orthopedic provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for inpatient hospital care (99232, 99233) on 
January 30 and February 10, 2020, a CTA scan of the chest (71275) on February 8, 2020, and an office visit 
with an out-of-network physician (99214) on March 9, 2020. 
 
You asked the Plan to waive the cost-sharing for inpatient hospital care, a CTA scan of the chest, and an office 
visit with an out-of-network physician. You say that you had no idea the providers you saw were out-of-
network. The Plan denied your request. The Plan says the correct cost-sharing was 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 20% 
coinsurance for inpatient hospital care. Your contract also says that enrollees must pay a $15 copayment per 
visit to an out-of-network provider's office. 
 
You have been asked to pay $62.68, or 20% coinsurance of the Plan-allowed amount of $313.47, for inpatient 
hospital care on January 30, 2020. You have also been asked to pay $20.32, or 20% coinsurance of the Plan-
allowed amount of $101.62, for inpatient hospital care on February 10, 2020. You have also been asked to pay 
$60.86, or 20% coinsurance of the Plan-allowed amount of $304.29, for a CTA scan of the chest on February 8, 
2020. Lastly, you have been asked to pay a $15 copayment for an office visit with an out-of-network physician. 
Inpatient hospital care and a CTA scan of the chest fall within the "Inpatient hospital care" benefit category. An 
office visit with an out-of-network physician 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 cost-sharing for inpatient 
hospital care (99232, 99233) on January 30 and February 10, 2020, a CTA scan of the chest (71275) on 
February 8, 2020, and an office visit with an out-of-network physician (99214) on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on April 7, 2010, to April 15, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were quarantined in 
the Covid-19 ward. 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 $285 
copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care/in-
network.  
 
You have been asked to pay a $285 copayment per day for days 1-6. There is a $0 copayment for additional 
days for an inpatient hospital stay. The total amount you are being asked to pay is $1,170 ($285 x 6 days = 
$1,710). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided by a participating 
provider on April 7, 2010, to April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a CPAP device (E0601) and a humidifier 
(E0562) purchased on April 16, 2020. 
 
You asked the Plan to waive the coinsurance for a CPAP device and a humidifier. You say that you did not use 
the equipment due to lack of follow-up care by the provider. The Plan denied your request. The Plan says the 
correct coinsurance was 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 20% 
coinsurance for Medicare-covered durable medical equipment.  
 
You have been asked to pay $21.15, or 20% of the Plan-allowed amount of $105.76, for a CPAP device and a 
humidifier. A CPAP device and a humidifier fall within the "Durable medical equipment (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 a CPAP device (E0601) 
and a humidifier (E0562) purchased on April 16, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
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 July 9, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that you shouldn't have to pay this 
copayment because the pills they gave you at the ER didn't work and you had to follow-up with your doctor 
later to get a different medication. The Plan denied your request. The Plan says you were charged this amount 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for the ER services. This copayment applies regardless of 
whether or not you were satisfied with the service you received. 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 July 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy exercise services (97110) 
received on June 4, June 11, and June 18, 2020. 
 
You asked the Plan to waive the copayment for physical therapy exercise services. You say that you should 
only be charged one copayment for the 3 visits. The Plan denied your request. The Plan says the correct 
copayment was 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 physical and speech therapy.  
 
You have been asked to pay $120, or a $40 copayment for each one of 3 instances of physical therapy exercise 
services. Physical therapy exercise services fall 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 physical therapy exercise services (97110) received on June 
4, June 11, and June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99348) provided on August 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not 
supported. 
 
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 99348 is "Home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face 
with the patient and/or family". 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT 99348 is not supported by the records provided. Our coding reviewer found that the medical records 
provided indicate that a licensed vocational nurse performed this service, not the physician billing for this 
charge. Per Medicare, CPT code 99348 applies to a home visit performed by a physician or advanced 
practitioner such as a physician assistant (PA), therefore this service is not eligible for reimbursement 
consideration. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 99348) provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe new patient office or other outpatient visit (99204) provided on June 2, 2020, by an out of network (OON) provider.You asked the Plan to pay forthe new patient office or other outpatient visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe new patient office or other outpatient visit (99204) provided on June 2, 2020, by an out of network (OON) provider