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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
August 19, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to the hospital 
for treatment and were directed to the emergency room. The Plan denied your request. The Plan says the 
provider billed for the proper service and the correct copayment 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 $100 
copayment for per visit for emergency care.  
 
  You have been asked to pay a $100 copayment for an emergency room visit. An emergency room visit 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 an 
emergency room visit provided on August 19, 2021.  
 
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aortography billed for services provided on September 
21, 2021. 
 
You asked the Plan to pay for the billed service. You say that the medical records support the code. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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, the CPT Code Manual definition of code 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. We find that CPT code 75625 is not supported in the medical 
record. Specifically, the records do not include the interpretation of multiple images of the abdominal aorta 
near the renal arteries. There is a more appropriate code for the services described in the medical records. Based on this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for the aortography billed for services provided on 
September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) telehealth 
visit provided on October 19, 2021. 
 
You asked the Plan to waive the copayment for the PCP telehealth visit. You say that you were charged for two 
doctors on the same day for office visits when they should be telehealth visits. 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 $10 
copayment for each PCP visit, including telehealth services.  
 
You have been asked to pay a $10 copayment for the PCP telehealth visit. The PCP telehealth 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 primary care physician (PCP) telehealth visit provided on 
October 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the 
shoulder without contrast (73221). 
 
You asked the Plan to pre-approve an MRI scan of the shoulder. You say that the requested MRI scan of the 
shoulder is medically necessary. The Plan denied your request. The Plan says the requested MRI scan of the 
shoulder does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI scan of the shoulder. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the records do not 
show a detailed and complete physical exam of the right shoulder including impingement testing. Furthermore, 
the physician made a notation referring to physical therapy (PT) on July 19, 2021. Such a 6-week conservative 
treatment has not been attempted.  
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan of the shoulder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the shoulder without contrast 
(73221).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiography (ECG) (93351) 
provided on November 3, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that you should not be charged this 
copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your 
copayment was assessed in accordance with your contract. 
 
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 other outpatient diagnostic procedure and tests.  
 
You have been asked to pay a $45 copayment for the ECG. An ECG falls within the other outpatient diagnostic 
procedure and tests 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 the 
echocardiography (ECG) (93351) provided on November 3, 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without 
any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near his baseline 
and he can receive services at a lower level of care. 
 
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 pay for the chiropractic manipulative treatment (98940) rendered by 
the out-of-network (OON) provider on September 9, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98940) rendered by the out-of-network 
(OON) provider on September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on December 17, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on December 17, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous passive motion exercise device. 
 
You asked the Plan to pre-approve the continuous passive motion exercise device. You say that this is 
necessary for your physical therapy post-surgery. The Plan denied your request. The Plan says the requested 
use of this device does not satisfy the coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Instead, this is requested for use after hip surgery. Therefore, 
we decided that the Plan does not have to pre-approve the continuous passive motion exercise device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D interpretation and report rendered on October 11, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 76376 (3D rendering with interpretation and report) and 
78306 (whole body bone imaging). Code 76376 is a column II code with a modifier indicator of 1 when billed 
with column I code 78306. Code 76376 was not billed with an appropriate modifier to allow for separate 
payment. Therefore, we decided that the Plan does not have to pay for the 3D interpretation and report rendered 
on October 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transport (A0427), and ground 
mileage (A0425) provided on August 20, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services were not related to the 
enrollee's hospice diagnosis. 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 ambulance transport (A0427), and ground 
mileage (A0425) provided on August 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychosocial rehabilitation services (H2017) provided on 
September 9, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychosocial rehabilitation services. You say that the treating provider is in-
network, but with the merge this provider was not updated. The Plan denied your request. The Plan says this 
service was rendered by a non-participating provider, and there is no referring provider. The Plan also says that 
prior authorization was not 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychosocial rehabilitation services (H2017) 
provided on September 9, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone marrow or stem cell services/procedures and excision 
procedures on the lymph nodes and lymphatic channels provided on May 5, 2021. 
 
You asked the Plan to pay for bone marrow or stem cell services/procedures and excision procedures on the 
lymph nodes and lymphatic channels. The Plan denied your request. The Plan says the Plan requires utilization 
of network providers when possible and available and requires authorization for certain services. No medical 
necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented. 
  
 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 bone marrow or stem cell services/procedures and excision 
procedures on the lymph nodes and lymphatic channels provided on May 5, 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee received enteral nutrition and 
medications. The enrollee had stable vital signs and was at a maximal assist level with functional mobility. The 
enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romiplostim. 
 
You asked the Plan to pre-approve Romiplostim. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
 
  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 Romiplostim. Our reviewer says that 
Romiplostim is not medically reasonable and necessary in this case. Our physician reviewer found that 
Romiplostim should be used only when the degree of thrombocytopenia and clinical condition increase the risk 
for bleeding; Romiplostim should not be used in attempt to normalize platelet counts. Most invasive procedures 
required a platelet count of 50-80 and neurosurgical procedures a platelet count of 100. There is no evidence 
that plastic surgeries require a normal platelet count of 150. This drug is not medically reasonable or necessary, 
and not safe and effective for the 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 Romiplostim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Romiplostim.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for the 
services from August 17, 2021 to August 20, 2021.  
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan says that the 
enrollee improved with skilled care, and returned to baseline. 
 
We decided that the Plan has to pay for the services on August 16, 2021.  
 
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 for skilled nursing facility services. Our reviewer says 
that there were identifiable skilled nursing services on 8/16/21. Our physician reviewer found that this date 
should be covered as skilled for the administration of two liters of intravenous (IV) fluid via peripheral IV on 
8/16/21. After this, the IV was discontinued per resident request. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the services on August 16, 2021.  
 
We also decided that the Plan does not have to pay for the services from August 17, 2021 to August 20, 
2021. 
 
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 the remaining days of the skilled nursing facility stay. 
Our reviewer says that there were no further skilled nursing services needs, and no identifiable skilled therapy 
needs overall. Our physician reviewer found that the enrollee did not require skilled nursing or therapy services 
on a daily basis. The enrollee did not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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 the services from August 17, 2021 to August 20, 2021 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services from August 17, 2021 to August 20, 
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: 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 LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care 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 there is no documentation provided indicating medical necessity for admission to an 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. 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.