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

We decided that the Plan does not have to pay for domiciliary, rest home visit (99336) provided on July 30, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the home visit services. You say that your physician provided medically 
necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is 
seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 domiciliary, rest home visit (99336) provided on 
July 30, 2020 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 pacemaker evaluation provided on July 
24, 2020. 
 
You asked the Plan to waive the copayment for cardiology service. You say that you have had this service for 
over 7 years and have never had a 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 $20 
copayment for cardiology service. The record shows that the specialist physician component of this pacemaker 
evaluation was performed on July 24, 2020; therefore, the specialist copayment applies to this claim. 
 
You have been asked to pay $20 copayment for cardiology service. Cardiology 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 a pacemaker evaluation provided on July 24, 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 enrollee needs a higher level of therapy. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for a swollen painful arm and mental status changes. He was treated for a blood clot in the arm and a 
subdural hematoma. Medical conditions are stable. There are no medical needs requiring inpatient admission. 
There are no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record documents a need for physical and occupational therapy, it does not document a need 
for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil tablets. 
 
You asked the Plan to pre-approve the Tadalafil tablets. The Plan denied your request. The Plan says the 
enrollee's plan does not cover outpatient 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 Tadalafil tablets.  
 
Benefits for the Tadalafil tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion administration provided. 
 
You asked the Plan to pay for home infusion service. You say that these are payable services. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because the billed codes are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure codes 99601 and 99602 are not valid 
for Medicare purposes and are not payable.  
 
We looked at the file and Medicare rules. The procedure codes billed on this claim are not payable by 
Medicare. Based on this information, we decided that Medicare rules for coverage of home infusion service 
have not been met. Therefore, we decided that the Plan does not have to pay for home infusion administration 
provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train of four testing provided on June 8, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the cost is 
included in the cost of the primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the train of four testing is an integral part of the approved neuromonitoring services. The cost for 
the train of four testing is included in the payment for the approved services. Therefore, we decided that the 
Plan does not have to pay for the train of four testing provided on June 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on April 9, 2020. 
 
You asked the Plan to pay for the emergency room services. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for emergency room services provided on April 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 you need rehab. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the complexity of your nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. You were admitted to the hospital with a painful right hip and had a total hip 
replacement. Your medical conditions are stable. You have no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the routine mammogram and the ultrasound 
provided on August 27, 2020. 
 
You asked the Plan to waive the copayment for the routine mammogram and the ultrasound. You say that you 
believe the breast ultrasound should be covered in full due to your history or breast cancer. You say the 
ultrasound was done as a part of your routine mammogram. 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 $45 
copayment for each in-network Medicare-covered standard x-ray and ultrasound and that there is no 
coinsurance, copayment, or deductible for in-network covered screening mammograms.  
 
You have been asked to pay a $45 copayment for the ultrasound. The routine mammogram falls within the 
?Breast cancer screening (mammogram)? benefit category. The ultrasound falls within the ?Outpatient 
diagnostic tests and therapeutic services and supplies? benefit category. The record shows a $0 copayment was 
applied to the mammogram. The record shows that the ultrasound is considered a diagnostic test. 
 
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 routine mammogram and the ultrasound provided on 
August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a neurostimulator (L8680) provided on 
March 5, 2019. 
 
You asked the Plan to waive the coinsurance for a neurostimulator. You say that you should not be charged 
because the provider waited so long to submit this claim. The Plan denied your request. The Plan says this 
service processed 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a $1,120 coinsurance for a neurostimulator ($5,600 allowed amount x 20% = 
$1,120). The records confirm that this was provided to you. 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 neurostimulator (L8680) provided on March 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered not medically necessary and investigational. 
 
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 the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is considered experimental/investigational because of the wide variation in efficacy in the 
published literature. Therefore, the request is considered 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF System. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of atrial 
fibrillation, coronary artery disease, and NYHA Class III congestive heart failure with preserved left 
ventricular ejection fraction requiring hospital admission. In this circumstance, therapy change based on data 
obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help 
reduce hospital readmission compared to standard medical therapy. The efficacy of the CardioMEMs device is 
uncertain and the services are not the standard of care. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs HF System.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network 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 services from an out-of-network provider cannot be approved without further 
information. 
 
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 provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health and home physical therapy. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a tibial fracture after a fall. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services provided on February 11, 
2019. 
 
You asked the Plan to pay for the emergency department services. You say that the claim was filed within the 
applicable time limit. The Plan denied your request. The Plan says the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department services was not filed until February 18, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the emergency department services provided on 
February 11, 2019.
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 you are appealing denial of acute rehab. The Plan 
denied your request. The Plan says IRF admission is not medically necessary. Services can be safely provided 
in other settings such as skilled nursing facility or home with home health and home physical therapy. 
 
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 there are no medical needs requiring inpatient admission. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 reimburse you for the limited oral evaluation (D0140) provided. 
 
You asked the Plan to reimburse you for the dental service. You say that the services would have been covered 
had you broken your nose, injured your eye or broke your jaw. You also say that this claim should be adjusted 
to a medical issue. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a 
covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the limited oral evaluation (D0140) provided.