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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
February 15, 2022, to February 19, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you cannot afford this bill 
so it should be waived. The Plan denied your request. The Plan says the copayment applied 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 $275 
copayment per day for days 1 through 5.  
 
You have been asked to pay $1,100 ($275 x 4 days) copayment for inpatient hospital stay. Inpatient hospital 
stay 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 stay provided from February 15, 2022, to February 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator rental. 
 
You asked the Plan to pre-approve portable oxygen concentrator rental. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator rental Our 
reviewer says that the documentation does not support that the requested portable oxygen concentrator rental is 
medically reasonable or necessary. Our physician reviewer found the enrollee has diagnoses of chronic 
obstructive pulmonary disease (COPD), unspecified, as well as asthma, heart disease, diabetes, and 
hypertension. The cardiovascular note dated March 21, 2022, is a Telehealth visit and does not document 
hypoxia. The Adult Progress Note dated March 31, 2022, does not document hypoxia. Therefore, the enrollee 
does not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable oxygen concentrator rental have not been met. Therefore, we decided 
that the Plan does not have to pre-approve portable oxygen concentrator rental.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided to the enrollee on December 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 this was not billed properly. 
 
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 88300 
is a column II code to column I code 88309 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for pathology services provided to the enrollee on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 01, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you were informed there would be no 
copay for this visit. You were told it would be included with your surgery copay. 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 $10 
copayment for each covered visit or consultation in an outpatient location with your primary care provider 
(PCP) or other primary care provider. Covered services include consultation, diagnosis, and treatment by a 
specialist. 
 
You have been asked to pay a $10 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's 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 office visit on April 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70551 billed for date of service March 25, 
2022. 
 
You asked the Plan to pay for procedure code 70551. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70551 is bundled into payment 
for code 70553.  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 70551 
is a column II code to column I code 70553. 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 70551 billed for date of service March 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically 
ill or critically injured patient; first 30-74 minutes (99291) provided on November 18, 2021. 
 
You asked the Plan to pay for the critical care. You say that the claim should be paid. 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 critical care, evaluation and management of the critically 
ill or critically injured patient; first 30-74 minutes (99291) provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer you purchased on November 9, 2021. 
 
You asked the Plan to pay for the nebulizer. You say that you have been trying to get this issue resolved for 
months and want to be reimbursed for the nebulizer you purchased. The Plan denied your request. The Plan 
says this claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. It 
appears as though there are two errors with the claim that this durable medical equipment (DME) provider 
submitted.  First, the provider billed with an incorrect diagnosis code.  The diagnosis code the provider put on 
the claim is R05.  The issue with this is that R05 is a generic, over-arching code for a host of conditions that 
fall under the category of Cough.  This code (R05) should not be used for reimbursement purposes as there 
are multiple subcodes below it that contain a greater level of detail.  That means that this provider should have 
billed the more specific sub-code that accurately represents your diagnosis.  
 
Second, according to your appeal letter, it appears as though you purchased this item.  However, this DME 
provider billed this as a rental (i.e., they appended the RR modifier which indicates it is a rental item.) Until 
these two issues are resolved, the claim is not payable.  In addition, because this DME provider is not a contract 
provider with the Plan, the Plan has no control over how this provider bills.  The provider would need to 
correct the billing in order for the Plan to proceed with processing this claim. Based on this information, we 
decided that Medicare rules for coverage of the nebulizer have not been met. Therefore, we decided that the 
Plan does not have to pay for the nebulizer you purchased on November 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
May 18, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the medically necessary services were 
rendered to the enrollee in good faith. 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 subsequent nursing facility care (99308) provided on May 
18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy provided by a participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that all 30 PT sessions are medically necessary. 
The Plan denied your request. The Plan says 15 of the 30 requested PT sessions have been approved. 
 
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 physical therapy. 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 provided records do not support that the complexity of the enrollees 
conditions are such that the skills of a professional therapist will likely still be required to achieve further 
improvement in the enrollee's symptoms or functional status after completion of the 15 approved physical 
therapy sessions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering provider is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under open access unless preauthorized. 
 
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 subsequent nursing facility care provided on 
February 10, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 5, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that supporting documentation is attached to process the 
claim. The Plan denied your request. The Plan says the provider must attempt to consult the attending or 
primary care physician about the services furnished. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on April 5, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on October 6, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that payment was made and then recouped. You 
say that the enrollee had 2 transports on the same day. You also say this should be reprocessed for payment. 
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 ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on October 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services of a registered nurse in the home 
health or hospice setting provided from January 19, 2022, to February 15, 2022, by an out-of-network provider. 
 
  You asked the Plan to pay for the skilled nursing services. You say that authorization is not required for skilled 
nursing services. The Plan denied your request. The Plan says the services were not referred by a network 
provider or rendered in an in-network facility, nor were these services urgent or emergent, and they were not 
approved in advance. 
 
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 skilled nursing services of a registered nurse in the 
home health or hospice setting provided from January 19, 2022, to February 15, 2022, by an out-of-network 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the ventilator is to be used for the 
treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
with settings that could be delivered by BiPAP with AVAPS for this member with COPD 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 a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
chronic hypoxic and hypercapnic respiratory failure from chronic obstructive pulmonary disease. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. You could be treated with a BiPAP machine with AVAPS capability. The plan has 
indicated coverage for such a device is available upon request. The elements of the coverage criteria are not 
satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on May 1, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were under the 
impression that COVID-19 testing was covered when you are exposed. 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 a $45 
copayment for each urgent care visit to a provider other than your PCP.  
 
You have been asked to pay a $45 copayment for the urgent care visit. Please note that there is no charge for 
the test itself, only for the visit location. The urgent care visit falls within the Urgently Needed 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 urgent care visit provided on May 1, 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 the enrollee would benefit from LTACH 
care. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 appears to be improving but is still somewhat unstable 
neurologically and requires additional short-term acute care services that can be administered safely at the 
current facility until more stable and appropriate for a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Transfer to an LTACH is not 
medically necessary as the patient is not yet stable for transfer and as it would not be clinically advantageous. 
Completion of treatment at the current facility is recommended. 
 
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.