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

We decided that the Plan does not have to pay for the discharge day services (99239) provided on March 17, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

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 99239 is "Hospital discharge day management; more than 30 minutes".

We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that more than 30 minutes of hospital discharge day management services were provided on the date of service in question. 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 the discharge day services (99239) provided on March 17, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided on May 
24, 2021.  
You asked the Plan to waive the copay for the services provided. You say that you should not have to pay twice 
for one injury. The Plan denied your request. The Plan says the claim processed 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 $90 
copay for each emergency care visit.   
You have been asked to pay a $90 copay for each emergency care visit. The services fall 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 copay for the emergency room services 
provided on May 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialty care transport (A0434) provided April 5, 2021.
You asked the Plan to waive the copayment for the specialty care transport. You say that it wasn't your choice to take an ambulance and you don't feel you should have to pay for it. The Plan denied your request. The Plan says the copayment was applied 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 $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $250 copayment for the specialty care transport. The specialty care transport falls 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 the specialty care transport (A0434) provided April 5, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 17, 2021, 
through March 24, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says that the inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission, the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 17, 2021, through March 24, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) and the trimming of skin lesions 
(11055) rendered by the OON provider on May 5, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 must 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 services at issue in this appeal. 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 the office visit (99204) and the trimming of skin lesions (11055) rendered by the 
OON provider on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard and accessories 
(CPT code(s): K0861, E2361 X 2, E1028 X 4, E2377, E2313, E2323, E1007, E2300, E2620, E2311, E0955, 
K0108 X 6, E1012, E0953 and E2607), for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says power wheelchair (Group 3 Power Wheelchair with Multiple Power Options) is 
medically necessary when a person has need for power tilt and power recline. The Plan states the notes do not 
show that the enrollee has s medical need for these power options. The Plan states upgraded electronics 
(expandable controller, harness and electronics) cannot be covered per Medicare rules. The Plan states there is 
not a medical need to control more than two power options through the joystick. The Plan states the seat lift 
and transfer handles do not serve a primary medical purpose. The Plan states these cannot be covered. The Plan 
states the calf pads and covers are already included with the requested wheelchair. The Plan states these cannot 
be covered separately. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found the requested Group 3 power wheelchair with multiple power options and accessories is not medically 
necessary per the LCD Power Mobility Devices (L33789). The enrollee does not use a ventilator mounted to 
the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is 
no evidence of intermittent catheterization, spasticity, or evidence of being high risk for a pressure ulcer. While 
the enrollee has a Group 3 qualifying neurologic diagnosis there is no evidence the enrollee requires the tilt and 
recline therefore the requested wheelchair and accessories is not medically necessary. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 standard and accessories (CPT code(s): K0861, E2361 X 2, E1028 X 
4, E2377, E2313, E2323, E1007, E2300, E2620, E2311, E0955, K0108 X 6, E1012, E0953 and E2607), for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from December 12, 2020, to December 14, 2020.
You asked the Plan to waive the copay for the services provided. You say that the copay should be waived. The Plan denied your request. The Plan says the information did not show there was a $0 copay for an inpatient stay.
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 $285 copay per day for days 1 through 7 for inpatient hospital care.
You have been asked to pay a $285 copay each day, for 2 days of inpatient care. The services fall 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 copay for the inpatient hospital services provided from December 12, 2020, to December 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote pacemaker reading (93296, 
93294) provided on March 15, 2021, and March 17, 2021. 
 
You asked the Plan to waive the copayment for the remote pacemaker readings. You say that you have had this 
pacemaker for three years and have never been charged for the reading with your previous insurance. The Plan 
denied your request. The Plan says this claim 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 $40 
copayment for outpatient diagnostic procedures and tests.  

You have been asked to pay a $40 copayment for the remote pacemaker readings. The remote pacemaker 
readings fall within the outpatient diagnostic procedures 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 remote pacemaker reading (93296, 93294) provided on March 15, 2021, and 
March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1833) for the enrollee. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says knee instability must be documented by examination. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no recent evidence of knee injury or knee surgery. Knee instability is not documented on 
examination. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a knee orthosis (L1833) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (77063, 77067) provided on April 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit of these 
services was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that an additional unit of code 77063 and code 77067 is not supported in the medical record. 
Specifically, the records show that one unit of code 77063 and one unit of code 77067 were provided on the 
date of service in question. These services were previously paid by the Plan. The records do not support that 
more than one unit of each of these codes was provided on April 13, 2021. 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 the services (77063, 77067) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a cardiothoracic surgeon.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation received indicates that needs can be met in-network.

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 an out-of-network referral for a cardiothoracic surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has respiratory failure due to 
Coronavirus pneumonia and now post Coronavirus syndrome. The Plan denied your request. The Plan says the 
stay is not medically necessary. 
 
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 necessitating admission to a 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 they are 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 LTACH services.
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) for the enrollee.
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 the services could be provided in another setting, for example, an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care.
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 necessitating admission to a 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 admission to a long-term acute care hospital (LTACH) for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on March 24, 2021.
You asked the Plan to pay for the non-emergent transport. You say that these services were medically necessary as the enrollee could not use any other form of transportation. The Plan denied your request. The Plan says transportation via ambulance for a scheduled doctor's appointment is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Documentation indicates the enrollee needed the transportation to attend a follow-up appointment with their physician. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (CPT code 99202) provided on April 19, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the provider did not assist with anything and that they should not be paid. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the medical records show that you received the office services provided on April 19, 2021. You were asked to pay a $20 copayment for the office services.
Your 2021 EOC states that enrollees must pay a $20 copayment for each specialist visit for Medicare-covered benefits (Including Telehealth services). 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 office visit (CPT code 99202) provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81398, 81291, 81355, 81231, 81328, 
81400, 0031U, 0032U, 81225, 81226, 81227, 81230, 81479, 81401)) provided on May 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 laboratory services (81398, 81291, 81355, 81231, 
81328, 81400, 0031U, 0032U, 81225, 81226, 81227, 81230, 81479, 81401)) provided on May 10, 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 copay for the office visit provided on April 13, 2021.  
You asked the Plan to waive the copay for the services provided. You say that the provider is a Tier 1 provider. 
The Plan denied your request. The Plan says the copay applied 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 $25 
copay for services obtained from a Tier 2 primary care provider.   
The file shows that you received services from a Tier 2 provider. You have been asked to pay a $25 copay for 
the services provided. The services fall within the physician 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 copay for the office visit provided on April 13, 2021.