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

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on March 18, 2021. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was not enrolled in hospice on the 
date of service in this case. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 17, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that there was a referral from the enrollee's primary care 
provider, and you would like the claim reprocessed for payment. The Plan denied your request. The Plan says 
the rendering and referring providers are both OON providers and there was no approved authorization. Also, 
the service rendered was not urgent or emergent. 
 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 an office visit provided on January 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided on September 13, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital services. You say that the enrollee did not enroll into the Plan, and 
they thought they were covered under Medicare. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
  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 hospital services provided on September 13, 
2021, by an out-of-network (OON) provider.  
 
Your complaint about the enrollee never enrolling into the Plan 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the X-ray and laboratory services provided 
on January 12, 2022, and January 21, 2022. 
 
You asked the Plan to waive the copayment for the X-ray and laboratory services. You say that you should not 
be responsible for the copayments. The Plan denied your request. The Plan says the copayments have been 
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 $45 
copayment for Laboratory Services provided in an outpatient hospital, and a $100 copayment for basic radiological services provided in an outpatient hospital. 
 
You have been asked to pay $76.37 copayment for an X-ray. An X-ray falls within the Basic Radiological 
Services provided in an outpatient hospital benefit category. You were asked to pay $76.37 because the 
allowed amount is less than your copayment. You have also been asked to pay $30.36 copayment for 
laboratory services. Laboratory services falls within the laboratory services provided in an outpatient hospital 
benefit category. You were asked to pay $30.36 because the allowed amount is less than your copayment, 
bringing your total to $106.73. 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 X-ray and laboratory 
services provided on January 12, 2022, and January 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services (A0428-RJ, A0425-
RJ) provided on November 24, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that this claim was billed correctly and should 
be paid in full. The Plan denied your request. The Plan says this claim was billed with secondary diagnosis 
S88919A (complete traumatic amputation of unspecified lower leg, level unspecified, initial encounter). The 
medical records and notes provided do not support the use of this diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due.  
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ambulance transportation have 
been met. Specifically, diagnosis code S88919A was reported as a secondary diagnosis code on this claim, but 
this diagnosis is not noted or supported in the medical documentation provided. Therefore, we decided that the 
Plan does not have to pay for the ambulance transportation services (A0428-RJ, A0425-RJ) provided on 
November 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on September 24, 
2021. 
 
You asked the Plan to pay for therapeutic activities. You say that the Plan has failed to satisfy its payment 
obligations to the provider. The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that services of a PTA or an OTA shall not be billed 
as services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. In this case, the services of a PTA and/or an OTA were billed as 
services incident to a NPP's service. Based on this information, we decided that Medicare rules for coverage of 
therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for 
therapeutic activities (97530) provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on January 24, 2022, 
through January 28, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services provided on January 24, 2022, through January 28, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker (E0143) and sales tax (S9999), purchased on 
October 2, 2021. 
 
You asked the Plan to pay for the walker and sales tax. You say that the item should be covered. The Plan 
denied your request. The Plan says you obtained this item through a provider who is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker (E0143) and sales tax 
(S9999), purchased on October 2, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program such as an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 28, 
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 this code is not valid for Medicare purposes. 
 
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 CPT code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S2900 is not valid for Medicare purposes. 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 
surgical services provided to the enrollee on December 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on November 
18, 2021. 
 
You asked the Plan to pay for the services. You say that you needed to be transported via ambulance to the 
doctor's appointment. The Plan denied your request. The Plan says the GY modifier was billed. 
 
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 the denied services are not supported in the medical record. Specifically, they were billed with the 
GY modifier, which means they are not considered medically necessary. 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 ambulance services provided to the enrollee on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the rendering provider is a non-participating provider, and the referring 
provider involved in these services is a non-participating provider with the Plan. The Plan also says that they 
did not authorize any services for this provider. 
 
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 provided on April 1, 2021, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on October 25, 2021. 
 
You asked the Plan to pay for occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on October 25, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility. 
 
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 there is not a reasonable expectation that the enrollee would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
does not require daily skilled nursing or therapy on an inpatient basis. 
 
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 continued services. Our physician 
reviewer found that the enrollee is walking with contact guard assistance, is at stand-by assist for transfers, and 
is independent or set-up assist with most activities of daily living. The records report no unstable medical 
conditions or need for intravenous medications, new tube feeding, or ostomy care or daily complex wound 
care. Although the enrollee requires skilled therapy services, the provided records do not document a 
significant decline in his functional status to necessitate further daily inpatient skilled therapy services. There is 
no documentation that he requires the services on an inpatient basis, only 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection (62320), provided on December 13, 2021. 
 
You asked the Plan to pay for the injection. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the records provided to the Health Plan are undated and unsigned. There is 
insufficient documentation of response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the injection (62320), provided on 
December 13, 2021. have been met. the required clinical records to support the medical necessity of the service 
for the date of service requested have not been received.. Therefore, we decided that the Plan does not have to 
pay for the injection (62320), provided on December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) on the fixed lift system, purchased on 
September 10, 2021. 
 
You asked the Plan to pay for the sales tax. You say that this should be covered. The Plan denied your request. 
The Plan says sales tax is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales 
tax.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999) on the fixed lift system, purchased on September 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide (HHA) services provided from July 12, 
2021, to August 5, 2021. 
 
  You asked the Plan to pay for the HHA services. You say that the enrollee is covered for home health care 
services per the Evidence of Coverage. You also say that the enrollee is no longer using this provider as they 
feel they were incompetent and used the wrong codes. The Plan denied your request. The Plan says this service 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay for the home health aide (HHA) services 
provided from July 12, 2021, to August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation procedure (64635, 64636). 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that the enrollee has tried home 
exercise and medication but continues to experience pain with daily activities. The Plan denied your request. 
The Plan says the requested radiofrequency ablation is not reasonable or necessary at this time. 
 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 radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the LCD criteria is greater than 80% pain relief for each set of diagnostic 
blocks. This was not achieved and therefore, the request is deemed not medically reasonable or 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation procedure (64635, 64636).