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

We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation
(93293) provided on July 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the cardiac device monitoring services. You say that you provided this service
out of good faith. Therefore, you expect proper reimbursement of your service. 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 had network providers available who could have provided 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 transtelephonic rhythm strip pacemaker evaluation (93293) provided on July 6, 2021 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 rest home visit provided on May 4, 2021 by an out-of-
network (OON) provider. 
 
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 services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 rest home visit provided on May 4, 2021 by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from May 11, 2020 
to May 15, 2020. 
 
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 submitted records do not support the billing of DRG 291 and secondary diagnosis 
code J96.01. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 291 (heart failure and shock with MCC) and 
secondary diagnosis code J96.01 (acute respiratory failure with hypoxia). We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for these services. Our reviewer says that the submitted records do not support the 
billing of DRG 291 and secondary diagnosis code J96.01. Our physician reviewer found the enrollee presented 
to the hospital with complaints of shortness of breath and rapid heartbeat. Chest x-ray showed pulmonary 
vascular congestion and he was admitted for congestive heart failure exacerbation. While the diagnosis and 
transient episode oxygen saturation of 86 percent on room air are noted, there is no documentation of persistent 
hypoxia. The records do not support the billing of DRG 291 and secondary diagnosis J96.01.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services rendered from May 11, 2020 to May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health custodial services provided January 29, 
2020, through April 3, 2020. 
 
You asked the Plan to pay for the home health custodial services. You say that you would like these claims 
reprocessed and approved for payment. The Plan denied your request. The Plan says custodial care is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health custodial services have not been met. Specifically, we find that the services at 
issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay 
for the home health custodial services provided January 29, 2020, through April 3, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) 
you received at a cardiologist's office on May 24, 2021. 
 
You asked the Plan to waive the copayment for the TTE. You say that you had to return on this date because 
there was no nurse available on May 20, 2021 to complete the test.  You don't think you should have to pay two 
separate copayments. 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 $30 
copayment for services in a specialist's office.  
 
You have been asked to pay a $30 copayment for the TTE. This copayment applies regardless of the reason for 
the service. 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 transthoracic echocardiography (TTE) 
you received at a cardiologist's office on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy (97802) and interprofessional telehealth consultation (99448) provided January 30, 2017 to February 4, 2017.
You asked the Plan to pay for the consultation. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says these services are bundled with another service.
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, we have confirmed that codes
97802 and 99448 are column II code to column I code 97535. This claim has not been billed with an
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy (97802) and
interprofessional telehealth consultation (99448) provided January 30, 2017 to February 4, 2017.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) services 
provided from January 1, 2021, through January 12, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing care. You say that you contracted the COVID-
19 virus during your stay and were forced to remain in the facility past 20 days in order to quarantine. You do 
not feel you should have to pay this since the facility exposed you to the virus and had no choice but to wait 
until the virus ran its course. The Plan denied your request. The Plan says you entered the skilled nursing 
facility on December 1, 2020, which means the benefit from the Plan's 2020 EOC applies. 

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 $0 
copayment, per day, for days 1 through 20 and a $178 copayment, per day, for days 21 through 100 for Skilled 
Nursing Facility (SNF) Care.  
 
You have been asked to pay a $178 copayment, per day, for 11 days of SNF services, which fall within the 
Skilled Nursing Facility (SNF) Care benefit category. You began your SNF stay on December 1, 2020, which 
means December 21, 2020 was the 20th day. Subsequent days of service fall under the days 21 through 100 
benefit. (January 1, 2021, through January 12, 2021 = 11 days. $178 x 11 days = $1958). 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 Skilled Nursing Facility (SNF) services provided from January 1, 
2021, through January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from May 26, 2021, to June 2, 2021.
You asked the Plan to waive the copayment for inpatient hospital services. You say that you do not believe that you should have a copayment because you have never had one in the past for this service. The Plan denied your request. The Plan says you were 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 $220 copayment per day, per admission for days 1-5 of inpatient hospital care. You have been asked to pay a $220 copayment per day per admission for days 1-5 for inpatient hospital services for a total of $1,100 ($220 x 5 = $1,100). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services provided from May 26, 2021, to June 2, 2021.
Your complaint about potentially receiving misinformation is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on June 
26, 2021, through June 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be 
covered. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment each time you are admitted to an acute care hospital for inpatient hospital care.  

You have been asked to pay a $300 copayment each time you are admitted to an acute care hospital for the 
inpatient hospital care. the inpatient hospital care falls within the inpatient hospital 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 the inpatient hospital care provided on June 26, 2021, 
through June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740), core buildup (D2950) and unspecified adjunctive procedure (D9999) provided on March 19, 2021.
You asked the Plan to pay for the dental services. You say that you chose this plan because you believed this dental treatment would be covered. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
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 pay for the porcelain/ceramic crown (D2740), core buildup (D2950) and unspecified adjunctive procedure (D9999) provided on March 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy
assistant on May 17, 2021.
You asked the Plan to pay for the physical therapy services. You say that the medical records required to
reprocess the denied claim are attached. The Plan denied your request. The Plan says we cannot confirm
Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA)
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they
do not meet the qualifications of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the physical therapy services have not been met. Specifically, the billing provider is a physician
assistant, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services
provided by a physical therapy assistant on May 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis you received at an outpatient hospital facility on June 14, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you have never been responsible for 
this service in the past. The Plan denied your request. The Plan says you were charged this copayment 
correctly.  The Plan says that because the allowed amount for this CT scan ($204.66) is less than your 
copayment obligation, you are responsible for the full allowed 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 $275 
copayment for diagnostic radiological services in an outpatient hospital facility.  
 
You have been asked to pay a $275 copayment for the CT scan. The CT scan falls within the diagnostic 
radiological services in an outpatient hospital facility 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 computed tomography (CT) scan of the abdomen and pelvis you received at an outpatient 
hospital facility on June 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound you received 
at an outpatient hospital on June 28, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you have had numerous services in 
the past and only had to pay a $10 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 $100 
copayment for ultrasounds.  
 
You have been asked to pay a $100 copayment for the ultrasound. 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 retroperitoneal ultrasound you received at an outpatient hospital on June 28, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a kidney ultrasound.
You asked the Plan to pre-approve a kidney ultrasound. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 a kidney ultrasound. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you are the ideal candidate to be followed yearly with ultrasound given the history of a small kidney and abnormal renal function tests. All criteria are met to authorize this exam. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a kidney ultrasound have been met. Therefore, we decided that the Plan has to pre-approve a kidney ultrasound.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the cleaning (D1110), periapical x-ray 
(D0220), covid fee (D1999), oral evaluation (D0150), filling (D2392), partial upper denture (D5213), partial 
lower denture (D5214), and occlusal guard (D9944) provided from November 4, 2020, to January 14, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the services should be 
covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says 
that out of network dentists may bill you for any amount greater than what the plan pays. The Plan also says 
that the occlusal guard 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 and the cleaning, x-ray, covid fee, oral 
evaluation filling, and partial dentures are listed as covered, out of network dentists may bill you for any 
amount greater than what the plan pays. Additionally, the occlusal guard is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the cleaning 
(D1110), periapical x-ray (D0220), covid fee (D1999), oral evaluation (D0150), filling (D2392), partial upper 
denture (D5213), partial lower denture (D5214), and occlusal guard (D9944) provided from November 4, 2020, 
to January 14, 2021.
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 this is medically necessary. The Plan denied your request. The Plan says you can be treated at a lower 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 in the Medicare rules section. 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 you do not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the documentation does support a need for physical or occupational therapy, there is
no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography (93306), provided on April 29, 2021.
You asked the Plan to waive the copayment for the echocardiography. You say that the incorrect cost share was applied. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $155 copayment for radiological diagnostic services. You have been asked to pay a $155 copayment for the echocardiography. This service 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 the echocardiography (93306), provided on April 29, 2021.