Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a physical therapy visit, and an 
occupational therapy visit provided from March 29, 2021, to March 30, 2021. 
 
You asked the Plan to waive the copayments for the physical therapy visit, and the occupational therapy visit. 
You say that you already paid your copayment for the outpatient surgery. The Plan denied your request. The 
Plan says the proper copayments were applied for the services that were billed. 
 
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 
copayment for each Medicare-covered physical therapy and occupational therapy visit. The total copayment 
amount was $50 ($25 physical therapy copayment + $25 occupational therapy copayment). 
 You have been asked to pay a $50 copayment for physical therapy and occupational therapy. The physical 
therapy and occupational therapy falls within Outpatient Rehabilitation 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 copayments for a physical therapy visit, and an occupational therapy visit provided 
from March 29, 2021, to March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), ophthalmic diagnostic imaging 
(92134), and dilated macular or fundus exam (G8397) provided on October 22, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the medical vision care. You say that you were directed to see this provider by 
someone in the Plan. The Plan denied your request. The Plan says this provider is not part of the Plan's medical 
network or the Plan's routine vision network. The Plan also says that no authorization or referral was submitted, 
and the services at issue were 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 office visit (99204), ophthalmic diagnostic 
imaging (92134), and dilated macular or fundus exam (G8397) provided on October 22, 2021, by an out-of-
network (OON) provider.  
 
Your complaint about potential misinformation from the Plan regarding in-network medical providers 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says completed studies say that this procedure does not improve outcomes compared to 
standard treatments. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered experimental/investigational because of the wide variation in efficacy reported in the 
literature. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this would help the enrollee's quality of 
life immensely and would keep the pressure sores clean and dry. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve Purewick incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of multi-layer compression system (29581) 
provided on May 24, 2021. 
 
You asked the Plan to pay for the application of a multi-layer compression system. You say that you would like 
reconsideration because the rules allow for 2 units of this service. The Plan denied your request. The Plan says 
this service exceeds the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29581 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
application of a multi-layer compression system have not been met. Therefore, we decided that the Plan does 
not have to pay for the application of multi-layer compression system (29581) provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 27, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. 
This means that the claim was billed with the incorrect POS code. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on May 27, 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 this was medically necessary. The Plan denied your 
request. The Plan says ongoing skilled therapy and nursing needs can be provided at a lower level of care, such 
as skilled nursing, on an intermittent basis at home with home health care, or in a long-term care setting. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met 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 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 admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
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 admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not require at least 3 hours a day/5 days a week, or 15 hours over 7 
consecutive days, of therapy services. The documentation does not support that you will 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: 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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on January 6, 2022 for treatment of acute respiratory failure secondary to COVID 
pneumonia. 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 she 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for out of network services from May 17, 2021, to August 12, 2021. 
 
You asked the Plan to pay for these services. You say that you did not know the provider was out of network. 
The Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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 out of network 
services provided from May 17, 2021, to August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on June 25, 
2021. 
 
You asked the Plan to pay for the special anesthesia service. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator 
of B. 
 
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 99100 is not supported in the record. Specifically, CPT code 99100 has a status 
indicator of B. This means that the payment for CPT code 99100 is always bundled into the payment for 
another service or procedure. Based on this information, we decided that Medicare rules for coverage of the 
special anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the 
special anesthesia service (99100) provided on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy procedure 
performed on August 10, 2021. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you feel the charges are excessive for 
the services. 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 $325 
copayment for surgery or other services provided at an ambulatory surgical center.  
 
You have been asked to pay a $325 copayment for the biopsy. The biopsy falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. Please note that while you listed the procedure as an ultrasound in your appeal, the file shows no 
evidence of a normal ultrasound performed. 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 fine 
needle aspiration biopsy procedure performed on August 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan injection services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve Hyaluronan injection services. You say that it is medically necessary for 
these services to be performed by an OON provider. The Plan denied your request. The Plan says there are in-
network providers that are available to provide the requested care. 
 
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 
Hyaluronan injection services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted special dermatological service or procedure, excimer 
laser treatment (96999) provided June 16, 2021. 
 
You asked the Plan to pay for the laser treatment. You say that you have provided medical records for review 
this service. The Plan denied your request. The Plan says this service is cosmetic surgery and is excluded from 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. The records show the laser treatment was for vitiligo. Based on this 
information, we decided that Medicare rules for coverage of the laser treatment have not been met. Therefore, 
we decided that the Plan does not have to pay for unlisted special dermatological service or procedure, excimer 
laser treatment (96999) provided June 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on May 28, 2021. 
 
You asked the Plan to pay for the transportation services. You say that the transport was provided prior to the 
enrollee's hospice election. 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 non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on May 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
June 29, 2021, through July 1, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $395 
copayment each day for days 1 to 4 for Medicare-covered hospital care.  
 
You have been asked to pay $790 ($395 copayment x 2 days) for the Medicare-covered hospital care provided. 
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 care provided from  
June 29, 2021, through July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 8, 
2020. 
 
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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 47350: 
 
Management of liver hemorrhage; simple suture of liver wound or injury 
 
CPT 49040: 
 
Drainage of subdiaphragmatic or subphrenic abscess, open  
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the record does not indicate the 
presence of hemorrhage and there CPT code 47350 is not supported by the record. CPT code 49040 has a 
procedural edit with, and is inclusive to CPT code 44143. The elements of the coverage criteria are not 
satisfied. 
 
We looked at this coder's review, the file, and Medicare rules. 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 October 8, 2020.