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

 
We decided that the Plan does not have to pay for hospice services provided from May 20, 2022, to May 25, 
2022. 
 
You asked the Plan to pay for the hospice services. You say that the patient's plan is part of the Value-Based 
Insurance Design (VBID) participation with Medicare, so this claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect Type of Bill for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that hospice providers must bill with the correct TOB 
code.  The only appropriate TOB codes for hospice services are 81(X) and 82(x).  You billed with TOB code 
831, which is not appropriate for hospice billing.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospice services have not been met. Therefore, we decided that the Plan does not have to pay 
for hospice services provided from May 20, 2022, to May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services provided on July 28, 2022. 
 
You asked the Plan to pre-approve psychotherapy services. You say that the psychotherapy services were 
medically necessary. The Plan denied your request. The Plan says the psychotherapy services were 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 psychotherapy services. Our reviewer 
says that the requested psychotherapy services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that based on review of the records provided, this enrollee was not showing 
any symptoms of agitation, anxiety, social isolation or worry. The enrollee had no suicidal thoughts. The 
enrollee did not show any withdrawal. The enrollee was alert and responsive. This enrollee did not show any symptoms of her illness, which would require a visit or treatment. This visit was found not to be reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychotherapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve psychotherapy services provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
August 3, 2022 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you want to know 
why the copayments are different. The Plan denied your request. The Plan says this cost sharing was charged 
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 $325 
copayment for in-network outpatient surgery/Medicare-covered outpatient hospital facility surgery.  
 
You have been asked to pay a $325 copayment for outpatient surgery services. However, you are only being 
asked to pay $56.67 which is less than the required amount. This item/service falls within the in-network 
outpatient surgery/Medicare-covered outpatient hospital facility surgery 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 outpatient surgery services provided on August 3, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided on February 
26, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that this equipment was medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The date of service 
billed does not match the shipping or delivery date noted in the records. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for a continuous glucose monitor (K0553) provided on February 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that services are medically necessary as the 
enrollee cannot survive at home. The Plan denied your request. The Plan says LTACH services requested do 
not meet the requirements for approval and the enrollee can safely receive care in another setting, such as a 
skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. The health plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for biopsy provided on August 18, 2020. 
 
You asked the Plan to waive the copayment for biopsy. You say that you feel you should not have to pay the 
copayment for this service. The Plan denied your request. The Plan says this cost sharing was charged 
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 $320 
copayment for hospital outpatient facilities and ambulatory surgical centers. 
 
You have been asked to pay a $320 copayment for biopsy. This item/service falls within the 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 biopsy provided on August 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care provided on 
August 4, 2022, to August 9, 2022. 
 
You asked the Plan to waive the copayment for inpatient mental health care. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged 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 $295 
copayment per day for days 1-6 for inpatient mental health care. This inpatient mental health care lasted 4 days, 
resulting a copayment of $1,180 ($295 per day for 4 days = $1,180). 
 
You have been asked to pay $295 copayment per day for days 1-6 for inpatient mental health care. This 
item/service falls within the inpatient 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 copayment for inpatient mental health care provided on August 4, 2022, to August 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0299, Q5001) provided on 
April 25, 2022 to May 24, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 G0151, G0299, & Q5001 are not supported in the medical record. Specifically, the 
date on the Notice of Admission does not match the dates of service billed. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided 
that the Plan does not have to pay for home health services (G0151, G0299, Q5001) provided on April 25, 
2022 to May 24, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) provided on 
February 24, 2022. 
 
You asked the Plan to pay for the outpatient visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit (99284) provided on 
February 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 12, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
contacted the emergency medical services because your heart rate had gone up very high, and you were 
nervous you were going to have a heart attack. You also say that the first responders were indecisive on if you 
should go to the hospital, and you were not advised that there would be any billed charges. The Plan denied 
your request. The Plan says this service is not covered under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 12, 2021. The record shows that you 
stated you were feeling better, and did not need an ambulance. The documentation further shows that you were 
told if you were transported by ambulance, they could monitor you and help you if it happened again, but you 
said you would be okay, and your husband said he would take you. The ambulance benefit is a transportation 
benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we 
decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) 
provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on February 25, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that the enrollee is in a facility and the 
facility should have obtained the prior authorization. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a skilled nursing facility visit provided on 
February 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital service provided on 
October 04, 2021. 
 
You asked the Plan to waive the copayment for an outpatient hospital service. You say that the injections were 
provided in a clean office suite. The Plan denied your request. The Plan says this cost sharing was charged 
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 $150 
copayment for outpatient hospital services. 
 
You have been asked to pay a $150 copayment for an outpatient hospital service. This item/service falls within 
the outpatient hospital services 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 outpatient hospital service provided on October 04, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for X-ray services provided on May 13, 2022. 
 
You asked the Plan to waive the coinsurance for X-ray services. You say that this is a covered benefit and you 
should not have to pay for it. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for X-rays. 
 
You have been asked to pay 20% coinsurance for X-ray services. This item/service falls within the X-rays 
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 X-ray services provided on May 
13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from June 3, 2022, to  
June 15, 2022. 
 
You asked the Plan to pay for self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs given to the member while in an outpatient setting at a facility are apt to be covered under 
the members Part D coverage whether that coverage is with the Plan or another company/Plan. 
 
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 pay for self-administered drugs provided 
from June 3, 2022, to June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services provided on 
August 4, 2022. 
 
You asked the Plan to pay for transitional care management services. You say that the member did not have 
any input in choosing who would be his provider and the provider has no prior knowledge of the patients they 
will be required to treat. The Plan denied your request. The Plan says non-emergent, non-urgent services with 
out-of-network providers require 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for transitional care management services provided on 
August 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (3LA21, G0299, Q5001) provided 
February 5, 2022 to March 6, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 code 3LA21, G0299, & Q5001 is not supported in the medical record. Specifically, the date 
on the Notice of Admission does not match the dates of service billed. Based on this information, we decided 
that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the 
Plan does not have to pay for home health services (3LA21, G0299, Q5001) provided February 5, 2022 to 
March 6, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on June 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tysabri (J2323). 
 
You asked the Plan to pre-approve Tysabri. You say that Tysabri is medically necessary. The Plan denied your 
request. The Plan says a trial of Ocrevus is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Tysabri. Our reviewer says that Tysabri 
is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drug, 
or any reason it would be unsafe or ineffective for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tysabri have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Tysabri (J2323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this is needed to complete the enrollee's 
surgery. The Plan denied your request. The Plan says studies have not proven that this is helpful for treatment 
of the enrollee's health problem. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 22, 2020. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
claim was received past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for subsequent nursing facility care was not filed until August 28, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on  
July 22, 2020.