Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit (G0463) provided on October 
1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that you were told that this provider was 
in-network with the Plan. You also say that this provider's facility is the only facility in the state that can 
perform the procedures that you need done since you are partially paralyzed and has a severe ulcer that will 
require intensive wound care surgery. The Plan denied your request. The Plan says the service was not urgent, 
emergent or preauthorized, and there are other providers in-network that provide the same service. 
 
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 hospital outpatient clinic visit (G0463) provided 
on October 1, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram and tomosynthesis provided on March 22, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mammogram and tomosynthesis. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the mammogram and tomosynthesis provided on March 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says this is an experimental procedure. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental and more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits (97139). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have had prior extensive PT for your condition and the 
documentation does not reveal that you require the unique skills of a professional therapist to safely and 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist. The documentation from the physician notes indicates identical 
shoulder exam findings on 12/14/21 and 2/10/22 and note only degrees external rotation. The notes indicate 
normal motor and sensory function. The documentation does not support that skilled therapy is needed. The 
requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve eight (8) additional physical therapy (PT) visits (97139).
Appeal type: Transportation
Decision: Partially Favorable

 
We decided that the Plan has to pay for the ambulance transportation and mileage from hospital to residence 
described by codes A0428-HR and A0425-HR. We decided that the Plan does not have to pay for the 
remaining billed services.  
 
You asked the Plan to pay for the ambulance transportation and mileage from hospital to residence described 
by codes A0428-HR and A0425-HR. You say that these claims are for medically necessary transports which 
occurred on the same date. The Plan says that code 94760 is not payable in this situation. 
 
We decided that the Plan has to pay for the ambulance transportation and mileage from hospital to 
residence described by codes A0428-HR and A0425-HR.  
 
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 code was denied on August 24, 2021, for being duplicate to another claim that was in process. The Plan 
failed to provide evidence of this other claim and failed to provide evidence that these services were paid. Since 
the Plan forfeited the opportunity to provide a valid denial rationale, we find that the denial is not substantiated.  
Therefore, we decided that the Plan has to pay for the ambulance transportation and mileage from hospital to 
residence described by codes A0428-HR and A0425-HR.  
 
We also decided that the Plan does not have to pay for the remaining billed services. 
 
The Plan follows Medicare rules. Medicare rules say that fee schedule payment for ambulance transportation 
and mileage is considered payment in full for ambulance services. No other payment can be made for 
separately billed items/services. 
 
These other billed services are included in the payment made for the base code and mileage code. Therefore, 
we decided that the Plan does not have to pay for the remaining billed services. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
February 5, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you should not have a copayment 
since the ER visit was COVID-19 related. 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 $90 
copayment for each emergency room visit.  
 
The file shows that the COVID-19 waiver guidelines do not include ER visits. Therefore, you have been asked 
to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an emergency room (ER) visit provided on February 5, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy assistant (OTA) services provided 
in the home on September 16, 2021. 
 
You asked the Plan to pay for the OTA services. You say that this is medically necessary care provided from a 
physician-led home care provider. The Plan denied your request. The Plan says this is not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA can only be billed 
incident to an occupational therapist's services. 
 
In this case, an NPP is billing for the services provided by an OTA. This is not allowed as the NPP is not an 
occupational therapist. Therefore, we decided that the Plan does not have to pay for the occupational therapy 
assistant (OTA) services provided in the home on September 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the sacral wounds are noted to be worsening. 
The enrollee's most notes from 3/20/22 - 3/22/22 indicate hyperkalemia, increasing neutrophils, thrombocytosis 
and a worsening sacral wound. She has had recent hallucinations and increasing weakness. The documentation 
is not clear that the enrollee needs SNF management at this time. Her needs appear to require more acute 
medical management at this time from the documentation. Functionally, she does not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and 
effectively provide medically necessary and reasonable treatment in a SNF as she is near baseline and with 
poor therapy participation. Given the worsening labs, worsening sacral wound the documentation does not 
support that the enrollee's needs are appropriate for a SNF at this time. 
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
coverage of LTACH services. 
 
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 the documentation does not support that the requested LTACH services are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. It is not clear 
from the clinical assessment in the case file that the enrollee is reasonably expected to benefit from, and 
improve with, LTACH 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment ambulance transportation services provided on 
October 31, 2021. 
 
You asked the Plan to waive the copayment the ambulance transportation services. You say that the services 
should be covered as it wasn't your decision to have them in the first place. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on 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 $250 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $250 copayment for ambulance transportation 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 ambulance transportation services provided on October 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing services provided on April 
10, 2021, to April 30, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing services. You say that you are not responsible 
for the copayment. The Plan denied your request. The Plan says the copayment amount charged is correct. 
 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 $184 
copayment for per day, for days 21-100. Since you had prior skilled nursing services within 60 days, this stay 
provided on April 10, 2021, to April 30, 2021 was grouped into the same benefit period. You had 27 days of 
skilled nursing care prior to this stay provided on April 10, 2021, to April 30, 2021, which made all 21 days of 
this stay subject to a $184 copayment per day. 
 
You have been asked to pay a $2,540.35 copayment for skilled nursing services, which met your maximum 
out-of-pocket limit. Skilled nursing services fall within the Skilled Nursing Facility (SNF) 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 skilled nursing services provided on April 10, 
2021, to April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
August 24, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that you thought the test was fully covered. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay $8.21, which is less than the $10 copayment for the ECG. The ECG falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an electrocardiogram (ECG) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99213) on July 19, 2021, with an 
out-of-network provider. 
 
You asked the Plan to pay for a physician office visit. You say that you were told that all your doctors are in-
network. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been 
met. 
 
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 a physician office visit (99213) on July 19, 2021, 
with an out-of-network provider.  
 
Your complaint about receiving erroneous or incomplete information about your network of providers from a 
representative of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Stelara injection provided on 
September 14, 2021. 
 
You asked the Plan to waive the copayment for the Stelara injection. You say that you would like the Plan to 
reconsider the coinsurance. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
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 20% 
coinsurance for chemotherapy and other drugs covered by Medicare Part B.  
 
 
 You have been asked to pay $250 for coinsurance for the Stelara injection. The total amount allowable by the 
Plan is $1250. You have been asked to pay 20% of this, which is $250 ($1250 x .2). The Stelara injection falls 
within the Medicare Part B prescription drugs 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 Stelara injection provided on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23430 billed with a -59 modifier for date of 
service December 15, 2020. 
 
You asked the Plan to pay for procedure code 23430-59. You say that these services should be paid. The Plan 
denied your request. The Plan says this code is inclusive to another code billed on the same claim and the -59 
modifier is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 23430-59 Our reviewer says 
that the use of the -59 modifier is not supported in this case. Our physician reviewer found you 
reported Current Procedural Terminology (CPT) 23430  Tenodesis of long tendon of biceps in a addition to a 
reverse shoulder arthroscopy for same date of service. Documentation submitted was reviewed, and does not 
meet criteria. The operative report describes a shoulder arthroscopy and a long tendon bicep tenodesis on the same extremity through same incision.  Therefore, CPT 23430 would not be separately reported, and modifier 
59 would be inappropriate to report 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 23430-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 23430 billed with a -59 modifier for date of service December 15, 
2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on March 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on March 4, 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.