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

 
We decided that the Plan does not have has to waive the copayment for emergency department services 
provided on February 2, 2022. 
 
You asked the Plan has to waive the copayment for the emergency department services. You say that you have 
met your deductible. The Plan denied your request. The Plan says you have met your deductible, but you have 
not yet met your Maximum Out-of-Pocket (MOOP) for emergency care services. 
 
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 4% 
coinsurance for emergency services in an emergency room and $80 Maximum Out-of-Pocket per visit for 
Emergency Care.  
 You have been asked to pay a 4% coinsurance for emergency services in an emergency room and $80 
Maximum Out-of-Pocket per visit for the emergency department services. The emergency department services 
falls 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 has to waive the copayment 
for emergency department services provided on February 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 14, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that diagnostic tests and procedures 
have a $40 copayment but were charged $174. You say that you paid the provider $40. The Plan denied your 
request. The Plan says you have been charged the correct copayment 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 $165 
in-network copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed 
in a physician's office or at a free-standing facility (such as radiology center or medical clinic).  You have been asked to pay $144.70 which is less than the standard $165 copayment for an ultrasound. An 
ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an ultrasound provided on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 14, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you reached your out-of-pocket 
limit and believe you should not be charged for this service. The Plan denied your request. The Plan says the 
copayment applied was 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 $10 
copayment for in-network medically-necessary medical or surgical services furnished in a physician's office.  
 
Please note your in-network maximum out-of-pocket was not met at the time this claim was submitted. 
 
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the 
Physician/Practitioner Services, Including Doctors 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 an office visit provided on December 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot take care of yourself and need skilled 
nursing. The Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF 
services do not meet the requirements for approval. 
 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator 
 
You asked the Plan to pre-approve the home mechanical (portable) ventilator 
. You say that you would like reconsideration because the device is to be used for the treatment of COPD. The 
Plan denied your request. The Plan says the Plan says the request for a home mechanical ventilator set in 
AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home mechanical (portable) 
ventilator. 
 Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found you have 
severe COPD, with mild CO2 retention when stable as an outpatient. You may benefit from BiPAP during 
sleep, with or without AVAPS.  This has not been tried.  Medicare does not pay for a ventilator when used as 
BiPAP.  Also, you have a Trilogy ventilator at home and are not using it enough to be beneficial, or to meet 
minimum Medicare requirements of at least 4 hrs/day for at least 70% of days. 
 
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 home mechanical (portable) ventilator 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical 
(portable) ventilator
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (75625, 75710, 37226, 75710, 37226) 
provided October 21, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 75625, 75710, 37226, 75710, & 37226 are not supported in the medical record. 
Specifically, the procedure report does not support the billed codes. Use of modifier 59 is not supported in the 
records. Based on this information, we decided that Medicare rules for coverage of the surgical services have 
not been met. Therefore, we decided that the Plan does not have to pay for surgical services (75625, 75710, 
37226, 75710, 37226) provided October 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on January 5, 
2022 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 outpatient mental health services provided on 
January 5, 2022 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health services for 6 physical therapy 
visits (G0151). 
 
You asked the Plan to pre-approve the home physical therapy visits. You say that the enrollee is making 
progress towards goals and would benefit from additional therapy to obtain previous functional level mobility 
and stability. The Plan denied your request. The Plan says services requested do not meet medical necessity 
criteria. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home physical therapy visits. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the available records the enrollee appears to have improved with 
therapy to the point of being able to manage ambulation of more than household distances with no assistive 
device with supervision and she is supervision level for transfers. After 26 physical therapy treatments, records 
do not support that the complexity of the enrollees conditions are such that the skills of a professional therapist 
are required to achieve further improvement in the patient's symptoms or functional status. Further utilization 
of the home exercise program appears appropriate at this point. 
 
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 home physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued home health services for 6 physical therapy visits (G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the power seat elevation feature for a 
power wheelchair purchased on December 31, 2021. 
 
You asked the Plan to provide reimbursement for the power seat elevation feature. You say that you understand 
that this is not covered by Medicare, but you believe that it should be considered medically necessary since you 
are not able to use your arms and legs. The Plan denied your request. The Plan says this is not an item that can 
be covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation systems are not primarily 
medical in nature. This means that they are not considered durable medical equipment and cannot be covered 
by Medicare.  
 
Although this feature may be appropriate for you, it is not covered by Medicare nor the Plan. Therefore, we 
decided that the Plan does not have to provide reimbursement for the power seat elevation feature for a power 
wheelchair purchased on December 31, 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 the enrollee requires aggressive therapy with medical 
oversight and his needs cannot be met at a lower level of care due to tracheostomy. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 19, 2021, to March 25, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were not aware of any 
copayment for a hospital stay. 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 $200 per 
day for days 1-10 and $0 per day for days 11-90 for each inpatient stay.  
 
The file shows that you were in the hospital from March 19, 2021, to March 25, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $200 per day for the first 6 days of inpatient care. The total for your stay is $1,200 ($200 copayment x 6 days = $1,200). The inpatient 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 
inpatient hospital care provided from March 19, 2021, to March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from June 28, 2021, to 
September 8, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you have provided medical records to 
support the necessity of these services. The Plan denied your request. The Plan says this patient exhausted their 
20-visit limit for acupuncture services related to chronic low back pain on April 19, 2021. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. The patient already received 20 covered acupuncture visits for the treatment of chronic low 
back pain for 2021, so no additional benefits are available. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for 
acupuncture services provided from June 28, 2021, to September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 12, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve irreversible electroporation ablation. 
 
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 large mass in the 
pelvis consistent with poorly-differentiated carcinoma. She is currently undergoing chemotherapy for 
malignant neoplasm of the bladder. The documentation is insufficient to demonstrate that irreversible 
electroporation ablation is medically reasonable and necessary for the enrollee in this case. Specifically, it has 
not been shown that irreversible electroporation ablation is an accepted standard of medical practice for the 
enrollee's diagnosis, and meets, but does not exceed, the enrollee's medical need, and is at least as beneficial as 
an existing and available medically appropriate alternative. 
 
 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 irreversible electroporation ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder monitor test provided January 12, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the test was ordered to aid in the diagnosis of 
recurrent bladder cancer The Plan denied your request. The Plan says this test is considered experimental and 
investigational and not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices 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 Cxbladder monitor test provided January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided November 21, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes 
a single procedural service, so one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple codes were submitted on another claim for this single panel. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided November 
21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 7, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says modifier 26 is not appropriate for this situation. 
 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 72170 
is a column II code to column I code 73502. 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 imaging services provided to the enrollee on October 7, 2021.