Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
November 17, 2022, to November 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $1,185 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,185 copayment for inpatient hospital care. This item/service 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 care provided on November 17, 2022, to November 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs a skilled nursing facility for 
aggressive physical therapy. The Plan denied your request. The Plan says that the enrollee's daily skilled 
services can be safely provided other than at an inpatient level of care. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilled nursing or therapy services. The 
enrollee does not meet the 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on June 2, 2022. 
 
You asked the Plan to pay for initial hospital care. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for initial hospital care. Our reviewer found the documentation 
does not support code 99223. The documentation available for review does not support the encounter required 
decision making of high complexity or included a comprehensive history or physical exam. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for initial hospital care (99223) provided on June 2, 2022.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are functioning at a home care level at a minimum. You do not require daily 
skilled therapy to restore or maintain function and you have no daily skilled nursing needs. Your functional 
status does not warrant nursing home skilled services. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 7, 2022, to 
February 22, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim should be paid. The Plan denied your request. The Plan says the review did not find sufficient 
documentation to clinically validate the diagnoses of A41.9 and R65.21. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 - sepsis, unspecified organism and R65.21 - 
severe sepsis with septic shock. 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 pay for the inpatient 
hospital services at the DRG originally billed. Our physician reviewer found the documentation does not 
consistently and completely support the assigned principal or secondary diagnoses codes with DRG. The 
replacement of DRG is upheld as it is supported by the medical documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 7, 2022, to February 22, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment program (OTP) services provided on November 
21, 2022. 
 
You asked the Plan to pay for the OTP services. You say that the OTP has been certified to bill Medicare for 
these services. The Plan denied your request. The Plan says that this service was billed by an individual 
physician which is not allowed. 
 
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 Plan's rationale incorrectly states that a physician is billing for these 
services. However, the claims data shows that the OTP is submitting a professional claim on its own behalf, 
which is allowed by the rules. Without an alternate denial rationale, we find that the denial of payment is not 
supported. Therefore, we decided that the Plan has to pay for the opioid treatment program (OTP) services 
provided on November 21, 2022.  
 
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 waive the copayment for the inpatient hospital stay provided from 
December 21, 2022, to December 29, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not have to 
pay because you were kept in the hospital against your will. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment per day for days 1-6 of each in-network inpatient hospital stay.  You have been asked to pay a $295 copayment per day for days 1-6 the inpatient hospital stay. You have been 
asked to pay a total of $1,770 ($295 copayment per day x 6 days = $1,770). This item/service 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 the inpatient 
hospital stay provided from December 21, 2022, to December 29, 2022.  
 
Your complaint about your treatment in the hospital 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the ambulance services provided on 
December 5, 2022. 
 
You asked the Plan to waive the cost share for the ambulance services. You say that you had to be transported 
twice due to a facility not being able to treat you. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $400 deductible which applies to out-of-network ambulance services. 
Your contract with the Plan also says that you must pay 2% coinsurance after meeting the deductible for out-
of-network ambulance services. 
 The item or service you asked the Plan to waive the cost share for falls within the out-of-network ambulance 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $400 deductible which applies to out-of-network ambulance services. You have been asked to pay $354.58 
towards your deductible. This cost sharing is a contractual obligation that had not been met at the time the 
ambulance services was received on December 5, 2022.  
 
The remaining allowed amount after the deductible was satisfied is $350.77 ($705.35 original allowed amount - 
$354.58 deductible paid = $350.77). You have been asked to pay $7.02, which is 2% coinsurance of the 
remaining allowed amount for the ambulance services ($350.77 remaining allowed amount x 2% coinsurance = 
$7.02). This item/service falls within the ambulance services benefit category. You have been asked to pay a 
total of $361.60 ($354.58 deductible + $7.02 coinsurance = $361.60). 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 cost share for the ambulance services provided on December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the onabotulinumtoxina injections and the 
specialist office visits provided from June 9, 2022, to December 2, 2022. 
 
You asked the Plan to waive the cost share for the injections and the specialist office visits. You say that you 
do not understand the price variation. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each specialist office visit for Medicare-covered services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay a $40 copayment for each of the specialist office visits provided on June 9, 2022, 
and September 1, 2022. These items/services fall within the physician/practitioner services, including doctors 
office visits benefit category.  
 
The records show that the injections vary based on the rate for each unit. You have also been asked to pay 20% 
coinsurance for each injection. These items/services fall within the Medicare Part B prescription drugs benefit 
category. 
 
Date of Service Code Allowed Amount 20% Coinsurance 
June 9, 2022 J0585 $927.75 $185.55 
June 9, 2022 J0585 $309.25 $61.85 
September 1, 20202 J0585 $744.84 $148.97 
December 2, 2022 J0585 $747.48 $149.50 
December 2, 2022 J0585 $498.32 $99.66 
 
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 cost share for the onabotulinumtoxina injections and the specialist office 
visits provided from June 9, 2022, to December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an enclosed walker with a four-sided frame described 
by code E0144. 
 
You asked the Plan to pre-approve the E0144 walker. You say that you feel that this is needed. The Plan denied 
your request. The Plan says the type of walker requested is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity of a walker described by 
E0144 is not supported. Therefore, we decided that the Plan does not have to pre-approve an enclosed walker 
with a four-sided frame described by code E0144.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist telehealth visit provided on 
September 29, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you did not have a 
telehealth visit. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for physician/practitioner services, including telehealth visits. 
 
You have been asked to pay a $30 copayment for the specialist telehealth visit. This item/service falls within 
the physician/practitioner services, including telehealth 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. The medical record shows you had a specialist 
telehealth visit on September 29, 2022. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist telehealth visit provided on September 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 20, 2021, 
through August 18, 2021. 
 
You asked the Plan to pay for the home health services. You say that the medical records support the billed 
Health Insurance Prospective Payment System (HIPPS) code 2KA11. The Plan denied your request. The Plan 
says the records do not support the billed HIPPS code 2KA11. 
 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 pay for the home health services. Our physician 
reviewer found the billing code 2KA11 was used despite the fact only 13 days elapsed between the episodes of 
care. The Plan has coded the services properly. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from July 20, 2021, through August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on October 12, 
2022. 
 
You asked the Plan to waive the copayment for x-ray services. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for outpatient diagnostic tests/xrays. 
 
You have been asked to pay a $15 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic tests/xrays 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 x-ray 
services provided on October 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 25, 2022, to 
August 28, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim should be paid. The Plan denied your request. The Plan says the Plan is upholding the Plan's decision to 
remove J96.21, acute and chronic respiratory failure with hypoxia and E43, unspecified severe protein-calorie 
malnutrition and assign ICD-10 CM diagnosis code J44.1, chronic obstructive pulmonary disease with (acute) 
exacerbation as principal diagnosis consistent with documentation received and maintain a change from DRG 
189 to DRG 191. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.21- acute and chronic respiratory failure with 
hypoxia and E43- unspecified severe protein-calorie malnutrition. 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 pay for the inpatient hospital services at the DRG originally billed. Our physician 
reviewer found the documentation does not consistently and completely support the assigned principal or 
secondary diagnoses codes with DRG. The replacement of DRG is upheld as it is supported by the medical 
documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 25, 2022, to August 28, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room service provided on 
September 15, 2022, to September 17, 2022. 
 
You asked the Plan to waive the copayment for the emergency room service. You say that you are not 
responsible for the emergency room visit. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for emergency care. 
 
You have been asked to pay a $65 copayment for the emergency room service. This item/service 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 the emergency room 
service provided on September 15, 2022, to September 17, 2022.