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

We decided that the Plan does not have to pay for a radiologic examination, physical therapy evaluation, and
therapeutic procedures provided from September 29, 2021, to October 26, 2021, by an out-of-network (OON)
provider.
You asked the Plan to pay for a radiologic examination, physical therapy evaluation, and therapeutic
procedures. You say that you requested to see an out-of-network provider because it was your best option. The
Plan denied your request. The Plan says there are in-network providers that provide the same quality of service,
and the service is not emergent in nature.
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 radiologic examination, physical therapy
evaluation, and therapeutic procedures provided from September 29, 2021, to October 26, 2021, by an out-ofnetwork
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extremity veins (93970) provided on June 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a duplex scan of extremity veins. You say that you disagree with the Plan's decision that the services were not medically necessary. The Plan denied your request. The Plan says this provider is a non-network provider with the Plan and another non-network provider with the Plan referred the member for services. The Plan also says there was no necessity for an out-of-network provider, such as an urgent or emergency situation that has been determined.
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 duplex scan of extremity veins (93970) provided on June 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the out-of-area office visit on February 1, 2021.
You asked the Plan to pay for the office visit. You say that the representative stated you were authorized to make an appointment, but you received a bill when returning from vacation. You say that you have adequate insurance to cover your medical costs and you shouldn't be held accountable. The Plan denied your request. The Plan says that the service was not referred by a network provider or rendered in a participating facility.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The records show the office visit was an out-of-state visit. The Plan did not submit medical records to support that this was not an urgently needed service when network providers were not available. Therefore, we decided that the Plan has to pay for the out-of-area office visit on February 1, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on February 27, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $250 copayment for ambulance services. You have been asked to pay the allowed amount of $236.26, which is less than the $250 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on February 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of prosthetic material or mesh (11008) provided on October 5, 2021.
You asked the Plan to pay for the removal of prosthetic material or mesh (11008). You say that the attached records should be reviewed, and the claim reconsidered for payment. The Plan denied your request. The Plan says CPT code 11008 was not billed with a primary procedure code.
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 11008 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the removal of prosthetic material or mesh (11008) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 4, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you were told that you would not
owe a copayment for follow-up visits. The Plan denied your request. The Plan says the claims were processed
correctly and you are being charged the correct 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 $35
copayment for each specialist visit.
You had a specialist visit on November 4, 2021. Follow-up visits are subject to cost-sharing charges.
Therefore, you are responsible to pay the $35 copayment.
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls 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 a specialist visit provided on November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopic cholecystectomy provided on January 28,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laparoscopic cholecystectomy. You say that authorization is not required for
this medically necessary service. The Plan denied your request. The Plan says no prior authorization was
obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laparoscopic cholecystectomy provided on January 28, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina (Botox) injection provided on June 8, 2021.
You asked the Plan to waive the coinsurance for the injection. You say that you were not made aware of the coinsurance when you enrolled in the Plan. The Plan denied your request. The Plan says the correct coinsurance was applied.
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 20% coinsurance for Part B drugs, including injectable drugs. You have been asked to pay $727.08, which is 20% of the allowed amount for the injection ($3,635.40 allowed amount x 20% coinsurance = $727.08). The injection falls within the Medicare Part B Prescription Drugs
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 an onabotulinumtoxina (Botox)
injection provided on June 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need SNF care. 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) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on
August 12, 2021.
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct 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 $20
copayment for urgently needed services.
You have been asked to pay a $20 copayment for urgently needed services. Urgently needed services fall
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
urgently needed services provided on August 12, 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 you need IRF care. The Plan denied your request. The Plan says your needs can be met 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 you are medically stable and do not need physical medicine and
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any
active or acute exacerbations of chronic medical conditions. At your current functional level, you do not need
intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with
multidisciplinary approach to daily therapy in an IRF. An IRF admission is not medically necessary based on
lack of medical complexity and lack of acute rehabilitation nursing needs. The documentation does not support
the necessity for admission to an IRF. Your rehabilitation needs can be met safely at a lower intensity and
alternate 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs you received during a hospitalization from September 21, 2021, to September 23, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you received these drugs while you were in the hospital, so they should be covered. The Plan denied your request. The Plan says self-administered drugs are not covered under your medical benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs you received during a hospitalization from September 21, 2021, to September 23, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on September 14, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you feel that the provider did nothing to treat you and you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care 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 to waive the copayment for emergency care provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) provided on November 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a hospital outpatient clinic visit. You say that the patient presented to you for symptoms of right ear pain, chills and body aches. The Plan denied your request. The Plan says this claim was denied because the services were not authorized by network/primary care providers. This provider is not a network provider with the Plan and the Plan has also determined that these services are not urgent or emergent, nor were they 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 a hospital outpatient clinic visit (G0463) provided on November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services, an X-ray, and does not have to waive the coinsurance for a Medicare Part B drug provided from August 13, 2021, to August 16, 2021.
You asked the Plan to waive the copayments for specialist services, an X-ray, and to waive the coinsurance for a Medicare Part B drug. You say that you already paid your deductible and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for specialist services, a $15 copayment for X-rays, and 20% coinsurance for Medicare Part B prescription drugs. You received specialist services, an X-ray and a Medicare Part B drug from August 13, 2021, to August 16, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service
Service
Allowed Amount
Amount You Owe
8/13/2021
Specialist Services
$109.20
$35
8/13/2021
X-ray
$33.32
$15
8/16/2021
Specialist Services
$96.42
$35
8/16/2021
Medicare Part B Drug
$12.25
$2.45
The total amount you owe is: $87.45. You have been asked to pay the total amount of $87.45 for specialist services, an X-ray, and a Medicare Part B drug. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for specialist services, an X-ray, and does not have to waive the coinsurance for a Medicare Part B drug provided from August 13, 2021, to August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 16, 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 a modifier was not billed on the claim to represent the services as separate/distinct.
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 73660
is a column II code to column I code 73630. 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 July 16, 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 needs inpatient rehabilitation or could end up back in the hospital. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.
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 enrollee is medically stable and does not need physical physician and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. An IRF admission is not medically necessary based on lack of medical complexity and lack of acute rehabilitation nursing needs. The documentation does not support the necessity for admission to an IRF. The enrollee's rehabilitation needs can be met safely at a lower intensity and alternate 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 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.