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

 
We decided that the Plan does not have to waive the copayment for the laryngoscopy procedure you had at 
your otolaryngologist's (ENT) office. 
 
You asked the Plan to waive the copayment for the laryngoscopy procedure. You say that you have to have this 
procedure regularly, so you shouldn't have a copayment. 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 $25 
copayment for surgery services in a specialist's office.  
 
You have been asked to pay a $25 copayment for the laryngoscopy procedure. The laryngoscopy procedure 
falls within the surgery services in a specialist's office 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 laryngoscopy procedure you had at your otolaryngologist's (ENT) office.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services provided on February 1, 2020 to February 
29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for dialysis services. You say that these services have never been denied before. 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. The Plan says that there is no network deficiency. 
 
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 dialysis services provided on February 1, 2020 to 
February 29, 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 by you on March 30, 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 March 30, 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 you on March 
30, 2020.
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 LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.

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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.

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: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the occupational and physical therapy services provided from March 
30, 2020 to March 31, 2020. 
 
You asked the Plan to pay for the occupational and physical therapy services. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
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. Specifically, the Plan denied the claim because at least one invalid modifier on 
the physical therapy codes was submitted. However, the Plan did not substantiate their reasoning for this 
denial. The Plan states at least one invalid modifier of the physical therapy codes was invalid; however, the 
Plan does not include what modifier is invalid and for what physical therapy codes. Furthermore, the Plan 
provided no documentation showing that Medicare will not allow payment the way the claim was billed. 
Therefore, we decided that the Plan has to pay for the occupational and physical therapy services provided 
from March 30, 2020 to March 31, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent wheelchair van transportation (A0130). 
 
You asked the Plan to pre-approve non-emergent wheelchair van transportation. 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 Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve non-emergent wheelchair van transportation (A0130).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you could end up back in the hospital without 
therapy. The Plan denied your request. The Plan says you do not require rehab physician management, or an 
interdisciplinary approach for 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 physician reviewer found 
that you are at a standby assist level for rolling, sitting up, walking, and standing up. You do not require the 
intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on April 22, 2020 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 April 22, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health physical therapy services (G0157) provided 
on July 30, 2019 to August 9, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the home health physical therapy services. You say that the records provided 
should support the necessity of the services. The Plan denied your request. The Plan says the provider is a non- 
Medicare approved and/or certified facility and therefore is not eligible for payment. 
 
Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is 
considered medically necessary and you receive your care from a provider who is eligible to provide services 
under Original Medicare As a member of the PPO plan you can receive your care from either a network 
provider or an out-of-network provider. 
 
The requested provider in this case is not eligible to participate in Medicare. A provider must be enrolled in the 
Medicare program in order to receive payment. 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 home health physical 
therapy services (G0157) provided on July 30, 2019 to August 9, 2019 by an out of network (OON) provider.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not need three hours a day of therapy and your medical illnesses 
are stable and you do not need a physician to monitor them three times a week. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as 
physical and occupational therapy but the documentation does not support that your functional status requires 
an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 
condition does not meet Medicare criteria for IRF 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulatory surgery services coded as 45380 and 45385  
provided on December 23, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the ambulatory surgery services. You say that you are appealing with a copy of 
the Medicare letter. The Plan denied your request. The Plan says the provider is a non-Medicare 
approved/certified provider as a surgical ambulatory center. The facility in question bills with NPI numbers 
that are registered as a supplier type: clinic/group practice. 
 
Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is 
considered medically necessary and you receive your care from a provider who is eligible to provide services 
under Original Medicare As a member of the PPO plan you can receive your care from either a network 
provider or an out-of-network provider. 
 
The requested provider in this case is not eligible to participate in Medicare. The Plan has network providers 
available who can provide the items/services at issue in this appeal. A provider must be enrolled in the 
Medicare program in order to receive payment. 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 ambulatory surgery services coded as 45380 and 
45385  provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads; 
interpretation and report only (93010) provided February 23, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that please see the attached medical records and 
reprocess for payment procedure code 93010 as this is a payable procedure code. The Plan denied your request. 
The Plan says the review is already included in the emergency department evaluation and management (E/M) 
payment. 
 
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 billing of code 93010 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another physician. This code can only be 
billed once per day Based on Medicare billing guidelines, this claim cannot be paid as billed. Therefore, we 
decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads; 
interpretation and report only (93010) provided February 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and 
panoramic x-ray (D0330) provided on June 8, 2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and panoramic x-ray. You say that you 
believe the x-rays should be covered because of a call you had with the Plan. You also say that you reached out 
to your previous dentist, but the new dentist wanted his own x-rays. The Plan denied your request. The Plan 
says you have reached the coverage limits for these benefits. The Plan also says that a representative from 
the facility called you on June 1, 2020 and left you a voicemail advising you would need to contact your 
previous provider for assistance with transferring your x-rays to your new dental office, since you had already 
met your x-ray benefit limit. 
 
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, complete series of intraoral x-rays 
(D0210) and panoramic x-ray (D0330) are limited to one procedure per 3 years. The record shows that you 
received a panoramic x-ray (D0330) on May 26, 2020 and your complete series of intraoral x-rays (D0210) and 
panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for the complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330) provided on June 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) with doppler. 
 
You asked the Plan to pre-approve TTE testing. You say that this test is medically necessary. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because this test is not 
medically necessary. 
 
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 TTE testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the records provided, the enrollee has asymptomatic mild grade aortic regurgitation on 
echocardiography and has no documented clinical cardiac changes since then. Current 
guidelines do not support repeat echocardiography under the circumstances. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transthoracic echocardiography (TTE) with doppler.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 inpatient psychiatric care. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based upon review of the records provided, the enrollee does not meet the criteria for 
continued acute inpatient mental health treatment for the dates in question of September 23, 2020 forward as 
this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual 
hallucinations and was cooperative/compliant with treatment while not showing any threats to the safety of 
herself or others as she was awaiting placement. 
 
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 care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray provided. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you did not want the X-ray, so you 
should not be charged for it. The Plan denied your request. The Plan says the copayment 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 a $20 
copayment for X-rays.  
 
You have been asked to pay a $20 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests 
and therapeutic services and 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 copayment for 
an X-ray provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and extraction 
provided on March 13, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and extraction. You say that during a 
call with the Plan, you were told the service would be covered. The Plan denied your request. The Plan says 
you received services from a Medicare opt out provider. The Plan also says that services performed by a 
privately contracted provider are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation and extraction provided on March 13, 2020.