Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99215, G2212) provided on March 
3, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a physician office visit. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network 
care have not been met. 
 
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 physician office visit (99215, G2212) provided 
on March 3, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve palliative care. 
 
You asked the Plan to pre-approve palliative care. You say that you need palliative care because you are 
suffering from extreme pain and every 3 months need stretching of your throat to be able to eat. The Plan 
denied your request. The Plan says palliative care is not medically necessary. You do not have a terminal 
illness and you should follow up with physical medicine, pain management and your primary care provider for 
treatment. 
 
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 palliative care. Our reviewer says that 
the requested palliative care is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided documentation does not show evidence of you being terminal due to any of 
your diagnoses and it was not explained in the documentation why palliative care would be more appropriate 
than the currently available physicians, including a pain specialist. Therefore, without sufficient support made 
for this request, palliative care will be considered not medically necessary at this time.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of palliative care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve palliative care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine received on November 17, 2021. 
 
You asked the Plan to pay for the vaccine. You say that you would like a reversal of this denial. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine received on November 17, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 11, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 11. However, the records do not show that the specimen was collected in an office setting. This 
means that the claim was billed with the incorrect POS code. 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 the lab services provided on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Watts 3D biopsy (88104, 88312, 88361, 88305). 
 
You asked the Plan to pre-approve the biopsy. You say that This service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 the biopsy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found the record indicates that the enrollee underwent upper endoscopy for a history of 
Barrett's esophagus. The literature does not support the safety and efficacy of the requested service, as defined 
by Medicare rules, for the enrollee's clinical condition. The American Society of Gastrointestinal Endoscopy 
has given the requested service a conditional recommendation for the noted use with low quality of evidence, 
insufficient to establish the safety and efficacy of the requested service. 
 
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 biopsy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Watts 3D biopsy (88104, 88312, 88361, 88305).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional payment for subsequent hospital care provided to 
the enrollee on June 13, 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 there is no additional documentation supporting an additional service which was billed and 
remains denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that two units of CPT code 99232 (Subsequent hospital care, per day, for the evaluation and 
management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of moderate complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 
minutes are spent at the bedside and on the patient's hospital floor or unit) are not supported in the medical 
record. The medical record only supports one unit of CPT code 99232. It is only appropriate to bill this code once per day. 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 pay for additional payment for subsequent 
hospital care provided to the enrollee on June 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end 
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 20, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Electrocardiogram (ECG) provided on 
October 19, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that the services should be covered. The 
Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $30 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $21.48 copayment for an ECG, which is less than the standard $30. ECGs fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an Electrocardiogram (ECG) provided on October 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for the ambulance service, advanced life support, 
emergency transport, level 1 (A0427) and ground mileage (A0425) provided September 5, 2021. 
 
You asked the Plan to provide coverage for the emergency ambulance transport and ground mileage. You say 
that the service was medically necessary. The Plan denied your request. The Plan says information provided at 
the time of the appeal does not support medical necessity for ambulance transport. 
 Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The rules say that an emergency exists based on a prudent layperson standard, 
not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a 
prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate 
medical attention would result in serious jeopardy to their health. 
 
We looked at the file and Medicare rules. We decided that this case does not meet prudent layperson criteria for 
emergency care. A prudent layperson would not reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Based on this information, we decided that Medicare rules for 
coverage of the emergency ambulance transport and ground mileage have not been met. Therefore, we decided 
that the Plan does not have to provide coverage for the ambulance service, advanced life support, emergency 
transport, level 1 (A0427) and ground mileage (A0425) provided September 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end 
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital procedure (36514) 
September 16, 2021 
 
You asked the Plan to waive the copayment for the outpatient hospital procedure. You say that the services 
should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
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 $300 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $300 copayment for a outpatient hospital procedure. 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 procedure (36514) September 16, 2021
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0428) provided on October 8, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $250 
copayment for each one-way Medicare-covered ambulance transport.  
 
You have been asked to pay $224.50 for the one-way Medicare-covered ambulance transport provided. This is 
the Plans allowable amount for this service which is less than the applicable copayment.  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 the ambulance transportation service (A0428) provided on 
October 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on April 
12, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for pneumatic 
compression devices have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.  
 PCDs are not covered for preventions of venous thromboembolism, regardless of how they are billed on the 
claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) 
provided on April 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care assistance (PCA) services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found in general, 
personal care assistant (PCA) services are not covered as a medical expense. Home health aide (HHA) services 
may be covered if they are provided in conjunction with HH skilled nurse or HH therapy services. No medical 
records have been submitted for review.  Therefore, there is no evidence that HH skilled nurse or HH therapy 
services are being provided to this enrollee. Therefore, there is no evidence that HHA services are medically 
necessary, reasonable or coverable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve personal care assistance (PCA) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve cardiac services. You say that it is necessary for these services to be 
rendered by an OON provider. The Plan denied your request. The Plan says there are in-network options 
available to perform the requested cardiac services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
cardiac services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be received in another setting. 
 
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 the enrollee was admitted with altered mental status and respiratory 
insufficiency.  The record indicates that the enrollee is improving but still requires acute care services prior to 
being appropriate  for transfer to lower level of care. The enrollee continues to receive acute care services and 
these have not been denied.  The medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH).
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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 you were admitted for lumbar laminectomy. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you 
have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. In conclusion, there is not a reasonable expectation that you 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 an inpatient hospital stay provided from 
October 10, 2021, to October 12, 2021. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that the services should be covered. 
The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $390 
copayment per day for days 1-5 of Inpatient Hospital Care.  
 
 
  You have been asked to pay a $780 copayment for 2 days of inpatient care $390 x 2 = $780). 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 inpatient hospital stay provided from October 10, 2021, to 
October 12, 2021.