Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 additional home health physical therapy visits for the 
enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not support the need for a skilled physical therapist to make 
more home visits at this time. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found 
that based on the medical records provided, there is no documentation that further skilled therapy services are 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the patient's level of function and/or 
prevent deterioration. Based on the available records, the patient appears to have improved with therapy to the 
point of being able to ambulate 200 feet independently with no assistive device and is independent for transfers 
and is supervision for stairs. After the 18 physical therapy treatment visits approved already, the records do not 
support the complexity of the enrollee's condition are such that the skills of a physical therapist are required to 
achieve further improvement in the patient's symptoms or functional status. Further utilization of the home 
exercise program and assistance from the assisted living staff as needed appears appropriate at this point. The 
provided do not document any acute or unstable medical conditions or changes in medication or treatment 
which would necessitate any further skilled therapy visits beyond what have already been approved. No 
medical notes from the enrollees treating physician are provided documenting an order or need for additional 
skilled therapy services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 11 additional home health physical therapy visits for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service March 7, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 code 
70450-26 is a column II code to column I code 70496-26. 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 procedure code 70450-26 billed for date of service 
March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 26, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this claim should be reprocessed. The Plan denied 
your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Neither the lab that provided these services nor the referring provider are network providers 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 lab services provided on 
October 26, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on 
December 3, 2021 and December 22, 2021. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that you need this 
chemotherapy but cannot afford this amount. The Plan denied your request. The Plan says the coinsurance 
amounts you are being charged are 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 5% 
coinsurance for in-network chemotherapy drugs. The allowed amounts of these claims total $17,373.60, 
resulting in a total coinsurance amount of $868.68. 
 
You have been asked to pay 5% coinsurance for chemotherapy drugs. Chemotherapy drugs fall within the Medicare Part B Prescription Drugs 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 
chemotherapy drugs provided on December 3, 2021 and December 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on 
January 22, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You did not provide an argument with 
your appeal request. 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 $50 
copayment per one-way trip for ambulance services.  
 
You have been asked to pay a $50 copayment per one-way trip for the ambulance services. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ambulance services you received on January 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve PT visits. You say that the enrollee requires continued PT services in order 
to improve dynamic balance, increase functional activity tolerance, increase independence with gait, increase 
lower extremity range of motion and strength. The Plan denied your request. The Plan says, based on the 
clinical information provided, the enrollee has not significantly changed from baseline function and the notes 
do not show the need for ongoing skills of a physical therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 PT visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent slow deterioration of the enrollee's 
condition. Our physician reviewer found the patient has had prior therapy, and the documentation does not 
reveal that the patient requires the unique skills of a professional therapist to safely and effectively provide 
treatment. Our physician reviewer also says the additional requested therapy generally is not accepted as 
specific and effective therapy for the patients condition beyond what was approved 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 PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 10 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and a portable gaseous 
oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and 
tubing (E0431). 
 
You asked the Plan to pre-approve an oxygen concentrator and a portable gaseous oxygen system. You say that 
the enrollee needs continuous oxygen therapy. The Plan denied your request. The Plan says the enrollee 
received an oxygen concentrator and a portable oxygen system on July 16, 2019. The enrollee has used 36 
months of this service. The rental period has capped, and the equipment is now purchased/owned. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly rental payments. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an oxygen concentrator and a portable gaseous oxygen system have not been met. Specifically, you 
have exhausted your benefit for the requested items. Therefore, we decided that the Plan does not have to pre-
approve an oxygen concentrator (E1390) and a portable gaseous oxygen system, rental; includes portable 
container, regulator, flowmeter, humidifier, cannula or mask, and tubing (E0431).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the requested provider is the provider who 
diagnosed the enrollee with cancer and who has offered a treatment plan. The Plan denied your request. The 
Plan says the enrollee must use network providers to get medical care and services when network providers are 
available. 
 
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 
an office visit to be provided 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 office visits, application of traction, massage, ultrasound, 
and electrical stimulation services provided by a chiropractor from October 15, 2021, to November 18, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that Medicare covers chiropractic services, and 
this has been covered in the past. The Plan denied your request. The Plan says the specific services you 
received are non-covered chiropractic services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visits, application of traction, massage, ultrasound, and 
electrical stimulation services provided by a chiropractor from October 15, 2021, to November 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided from 
February 23, 2022, to February 27, 2022, and telehealth psychotherapy sessions provided from February 2, 
2022, to April 27, 2022.  
 
You asked the Plan to waive the copayments for a hospital stay and therapy sessions. You say that you did not 
receive occupational therapy while you were in the hospital. You also say that no one explained you had to use 
a specific portal to receive telehealth services at no cost. 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 $250 
copayment for days 1-7 for an in-network inpatient hospital stay. The contract also says there is no charge after 
day 7. The Plan contract also says that enrollees must pay a $40 copayment for in-network individual therapy 
sessions. 
 
The medical record shows you were admitted as an inpatient and you received therapy services during your 
hospital stay from February 23, 2022, to February 27, 2022. You have been asked to pay $1,000, which is a 
$250 copayment for a four-day hospital stay from February 23, 2022, to February 27, 2022 ($250 copayment x 
4 days = $1,000). There is no charge for the day of discharge. A hospital stay falls within the Inpatient Hospital 
Care benefit category.  
 
You have also been asked to pay a total of $240, which is a $40 copayment for each therapy session from 
February 2, 2022, to April 27, 2022 ($40 copayment x 6 visits = $240). Therapy sessions fall within the 
Outpatient Mental Health 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 copayments for 
an inpatient hospital stay provided from February 23, 2022, to February 27, 2022, and telehealth psychotherapy 
sessions provided from February 2, 2022, to April 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays on January 05, 2022. 
 
You asked the Plan to waive the copayment for X-rays. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost-sharing 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 $0 or 
$15 copayment for Medicare covered X-rays. $0 copayment for X-rays in a primary care provider (PCP) or 
Specialist office. $15 copayment for X-rays in all other locations. Authorization not required for X-rays. 
Covered services include but are not limited to: X-rays.  
 
You have been asked to pay a $15 copayment for X-rays. X-rays fall 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 
X-rays on January 05, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment for emergency room services rendered on 
March 22, 2022. 
 
You asked the Plan to waive the $90 copayment for emergency room services rendered on March 22, 2022. 
You say that you cannot pay this. The Plan denied your request. The Plan says enrollees must pay a $90 
copayment for each emergency room visit in the United States. 
 
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 emergency room services rendered on March 22, 2022. 
Emergency room services fall within the Emergency 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 $90 copayment for emergency room services rendered on March 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that the additional sessions are medically 
necessary. The Plan denied your request. The Plan says there is nothing in the supplied documentation that 
supports that the services will be of such a level of complexity and sophistication, or the condition of the 
patient will be such that the services required can be safely and effectively performed only by a qualified 
therapist or under a therapist's supervision vs. home exercise program after the total approved visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found [state the medical finding(s) upon which the physician based his/her 
conclusion] 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy visits for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection coded as 87633, 87798 provided 
January 11, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the tests were performed using individual 
amplified probes. Therefore, you have appended modifier 59 starting from the second line item in order to 
report the service as a distinct and independent service. The Plan denied your request. The Plan says Multiplex 
PCR respiratory viral panels of 6 or more pathogens are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for infectious agent detection coded as 87633, 87798 provided January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 12, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these lab services are coverable and meet Medicare 
criteria. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Neither your lab nor the ordering provider is 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 lab services provided on October 12, 2021 by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 3, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 code 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON colonoscopy. You say that you were originally told by the Plan 
that this provider and facility were in network. You say that the OON provider has said that they will bill for 
the procedure regardless, because their cancelation policy is 10 days in advance. The Plan denied your request. 
The Plan says the services needed can be provided in-network. 
 
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 OON care. Therefore, we decided that the Plan does not have to pre-approve a 
colonoscopy to be provided by an out-of-network (OON) provider.