Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from August 31, 
2020, to September 1, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that an inpatient level of care is supported. 
The Plan denied your request. The Plan says this request is not medically necessary because the records show 
the enrollee responded to treatment during the observation period and did not have severe findings needing 
additional treatment and that this could be alleviated with a change in the medication they were taking.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 the inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital services provided from August 31, 2020, to September 1, 
2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 26, 2021, to 
September 3, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says that the inpatient admission and stay cannot 
be approved. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from August 26, 2021, to September 3, 2021.  
 
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 pay for the non-emergency ambulance transportation (A0428) 
provided on August 24, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation. The Plan denied your request. The 
Plan says the information provided does not support the ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the non-emergency ambulance 
transportation. Our reviewer says that the elements of the coverage criteria are not satisfied, and the requested 
service cannot be recommended. Our physician reviewer found the record indicates that the enrollee was 
transported to a wound care center. Our reviewer found that the enrollee was transported via stretcher. Our 
physician reviewer also found that the record does not indicate that the patient's clinical condition is such that 
other methods of transportation, such as stretcher van, were contraindicated. 
 
 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 non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) provided 
on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Radiofrequency Ablation (64635 and 64636). 
 
You asked the Plan to pre-approve Radiofrequency Ablation. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Radiofrequency Ablation have not been met. Specifically, this service has been requested for 
sacroiliac joint pain/dysfunction, which is considered not medically necessary or reasonable. Therefore, we 
decided that the Plan does not have to pre-approve Radiofrequency Ablation (64635 and 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involve needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular 
peripheral nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (K0800).  
You asked the Plan to pre-approve a POV. You say that the item is medically necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records say that you cannot safely 
transfer to and from a POV. 
 
The Plan must follow Medicare rules. Medicare rules say that a POV is covered if all the criteria listed in the 
Medicare Rules section of this letter are met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power operated vehicle (POV) (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right heart catheterization to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve right heart catheterization. You say that it is unsafe for him to be cared for 
anywhere but a high-volume, specialized pulmonary hypertension center such as the requested facility. The 
Plan denied your request. The Plan says this service can be provided by in-network specialists. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 right heart catheterization. Our reviewer 
says that the enrollee does not meet criteria to get service from an out-of-network provider. Our physician 
reviewer found there are credentialed physicians in-network that can perform right heart catheterization. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve right heart catheterization 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 medical services provided to the enrollee on October 14, 
2021 and billed under code 97110. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says code 97110 (1 unit) remains not supported. This code represents a therapeutic 
procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of 
motion and flexibility, however the records indicate that the service is performed by a physical therapist in a 
home health or hospice setting. There appropriate code for this service is G0151. The Plan states multiple 
attempts were made to contact the provider for additional information and a corrected claim.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case this claim cannot be paid as billed as it 
was submitted with an inappropriate code for the services billed. Therefore, we decided that the Plan does not 
have to pay for medical services provided to the enrollee on October 14, 2021 and billed under code 97110.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Mental Health provided on April 22, 2021 to 
November 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
office visit. 
 
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 Outpatient Mental 
Health provided on April 22, 2021 to November 24, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular gene testing provided on 
September 30, 2021. 
You asked the Plan to pay for the testing services. You say that payment should be reconsidered. The Plan 
denied your request. The Plan says the clinical effectiveness has not been demonstrated. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. It appears that the genetic testing may have been ordered by an unsolicited 
outreach telephone call to the enrollee. This request was not initiated by the enrollee or the enrollee's treating 
physician. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the hereditary cardiovascular gene testing provided on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 83540, 83550, 83970, 84100) provided 
October 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-Stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011 
 
We looked at the file and Medicare rules. The services billed are related to ESRD treatment and not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (82310, 83540, 83550, 
83970, 84100) provided October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a wheelchair power seat elevation system. You say that the item is 
medically necessary. The Plan denied your request. The Plan says this item does not primarily serve a medical 
purpose and is statutorily non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic esophagogastroduodenoscopy 
(43235) provided on July 21, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic esophagogastroduodenoscopy. You say that you 
were told by the Plan that there would be no copayment whatsoever for this procedure. 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 $325 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a $325 copayment for a diagnostic esophagogastroduodenoscopy. A diagnostic 
esophagogastroduodenoscopy falls within the outpatient surgery and other medical services provided at 
hospital outpatient facilities and ambulatory surgical centers 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 diagnostic esophagogastroduodenoscopy (43235) provided on July 21, 2021.  
 
Your complaint about potentially being misinformed by the Plan 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dorzol/Timol Sol eye drops. 
 
You asked the Plan to pre-approve Dorzol/Timol Sol eye drops. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the drug being requested does not fall under Part B 
coverage. The Plan says that the enrollee does not have pharmacy benefits administered under this contract. 
The Plan says that the enrollee has Teacher's Retirement System of KY which provides its own pharmacy 
benefits. 
 
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 Dorzol/Timol Sol eye 
drops.   
Benefits for Dorzol/Timol Sol eye drops 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulatory surgical services provided 
on October 5, 2021, and October 11, 2021 
 
You asked the Plan to waive the copayments for the ambulatory surgical services. You say that you were told 
the procedures would be covered and did not expect a higher copayment amount because it was done at a 
surgical center and not an office. The Plan denied your request. The Plan says the proper copayment was 
applied for the services that were rendered. 
 
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 $225 
copayment for each Medicare-covered ambulatory surgical center service. The copayment amount for both 
dates of service was $450 ($225 copayment amount x 2 dates of service). 
 You have been asked to pay a $450 copayment for the ambulatory surgical services. The ambulatory surgical 
service falls within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 the 
ambulatory surgical services provided on October 5, 2021, and October 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co-insurance for outpatient visits and drug tests from 
October 29, 2021 to December 3, 2021. 
 
You asked the Plan to waive the co-insurance for outpatient visits and drug tests. You say that your previous 
provider is gone, and he had to locate a new one that would accept you as a patient. The Plan denied your 
request. The Plan says the coinsurance 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 50% 
coinsurance for outpatient visits and drug tests. Total cost share amount is $449.95. 
 
You have been asked to pay a 50% coinsurance for outpatient visits and drug tests. Outpatient visits fall within 
the Physician/Practitioner services, including doctors office visits tests benefit category.  Drug tests 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 co-insurance for outpatient visits and drug tests from October 29, 2021 to 
December 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not 
require daily skilled services on an inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that you were admitted to the acute hospital with chest pain. You were diagnosed with an acute 
myocardial infarction and an acute decompensation of congestive heart failure. The most recent therapy 
documentation indicates you are able to ambulate short distances with a walker and contact-guard assistance. 
You can accomplish bed mobility without hands on assistance and require assistance for transfers. You are 
medically stable and do not have any complex daily wound care, parental medications or required care for a 
new or malfunctioning feeding tube. You do not require skilled nursing or skilled therapy services on a daily 
basis in an inpatient setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.