Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $90 copayment charged for emergency room services provided on May 4, 2021.
You asked the Plan to waive this copayment. You say that you were told this was an urgent care facility. The Plan denied your request. The Plan says the phone logs show you were given names of two urgent care facilities in your area and this provider is not one of them. This copayment was charged based on the type of services rendered and the claim submitted by the provider.
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 $90 copayment for emergency room services.
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 $90 copayment charged for emergency room services provided on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment),
without side rails, without mattress (CPT code E0295), bed side rails, half length (CPT code E0305) and
mattress, innerspring (CPT code E0271), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee retains a lot of liquid in their stomach
due to their wound. You state the enrollee's stomach liquid keeps leaking that is why they need to be at the 90-
degree angle to control the liquid from leaking and for the tool to drain the liquid. The Plan denied your
request. The Plan says the medical records did not show that the enrollee has a medical condition which
requires positioning of the body in ways not feasible with an ordinary bed, or that the enrollee requires
positioning of body in ways not feasible with an ordinary bed in order to alleviate pain.
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 documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in
ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The
documentation does not support a need for frequent or an immediate change in body position or special
attachments that cannot be fixed on an ordinary bed. The request for a hospital bed, semi-electric (head and
foot adjustment), without side rails, without mattress (CPT code E0295), and therefore the related items of bed
side rails, half length (CPT code E0305) and mattress, innerspring (CPT code E0271) are not medically
necessary for this enrollee.
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 hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress (CPT
code E0295), bed side rails, half length (CPT code E0305) and mattress, innerspring (CPT code E0271), for the
enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the arm joint.
You asked the Plan to pre-approve an MRI of the arm joint. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI of the arm joint. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has no clinical red flags to mandate immediate MRI without a trial of physical therapy. Likely, there is a chronic rotator cuff tear since the subacromial space was described as markedly narrow. Nonetheless, the medical necessity of immediate MRI has not been established. 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 MRI of the arm joint have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the arm joint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound repair by adjacent tissue transfer or rearrangement
(14041) provided on September 11, 2020, by an out-of-network provider.
You asked the Plan to pay for wound repair. You say that you were misinformed about the enrollee's insurance
type and that the treatment should be allowed based on the patient's age and special circumstances. The Plan
denied your request. The Plan says rules 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 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 wound repair by adjacent tissue transfer or rearrangement (14041) provided on September 11, 2020, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic imaging (92133) provided on April 5, 2021.

You asked the Plan to waive the copayment for ophthalmic diagnostic imaging. You say that you have never before had to pay an additional copayment for the service at issue. The Plan denied your request. The Plan says the correct copayment was applied.

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 $50 copayment for all other Medicare-covered outpatient diagnostic tests. 

You have been asked to pay a $43.76 copayment for ophthalmic diagnostic imaging. Ophthalmic diagnostic imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to 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 ophthalmic diagnostic imaging (92133) provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675)
provided on September 29, 2020.
You asked the Plan to pay for intermittent limb compression devices. You say that the requested items are a
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices
are not covered by Medicare for prevention of deep vein thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression
devices (E0673, E0675) provided on September 29, 2020.
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.
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 based on the medical records provided the complexity of your nursing, medical
and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on May 10, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says payment for the services is included in the facility payment.
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective payment systems are payment in full for all inpatient hospital services. We looked at the file and Medicare rules. Payment for billed procedure code 30999 (unlisted procedure, nose) is included in the payment to the inpatient hospital facility. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on May 10, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for Skilled Nursing Facility (SNF) services billed with Patient Driven 
Payment Model (PDPM) code KDXE1x27 days and provided on July 1, 2020, through July 27, 2020. 
 
You asked the Plan to pay for the SNF services billed with PDPM KDXE1x27 days. You say that you would 
like reconsideration because the section GG Clarification Form is used with the intent and purpose of 
documenting the residents best representation of his usual functional ability as instructed in the RAI manual, 
based on a compilation of the assessments, direct  observations  and the  residents  interactions in different 
locations and circumstances within the 3 day assessment period which is the first 3 days of the admission 
assessment. The Plan denied your request. The Plan says that only documentation that identifies the Section 
GG activity as described in CMS's RAI Manual Section GG can be used to support assessment coding and the 
documentation must indicate assessment occurred days 1-3 of the skilled stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not verified which criteria have not been met. Of note, 
the Plan's argument in regard to days 1-3 is not verifiable. The record includes the assessment which is done 
upon the member's admission. It is the burden of the Health Plan to substantiate their denial with evidence. In 
this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that 
the Plan has to pay for Skilled Nursing Facility (SNF) services billed with Patient Driven Payment Model 
(PDPM) code KDXE1x27 days and provided on July 1, 2020, through July 27, 2020.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $240 copayment charged for ambulance transports 
provided on May 18, 2021 and May 25, 2021. 
 
You asked the Plan to waive these copayments. You say that the transport was very short and you dont believe 
the copayment is fair. The Plan denied your request. The Plan says these copayments are contractual 
obligations. 
 
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 $240 
copayment for each one-way ambulance transport.  
 
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 $240 copayment charged for ambulance 
transports provided on May 18, 2021 and May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675) 
provided on September 15, 2020. 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the items at issue are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare for prevention of deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
devices (E0673, E0675) provided on September 15, 2020.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
 
 
 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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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: Transportation
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 October 8, 2020. 
 
You asked the Plan to pay for the transportation services. You say that the services should be covered. The Plan 
denied your request. The Plan says the payment made by the enrollee's primary insurance exceeded the 
allowable amount. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must identify payers that are primary to 
Medicare, identify the amounts payable by the primary payer, and coordinate benefits to Medicare enrollees with the benefits of the primary payer. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transportation services have not been met. Specifically, the file shows that the enrollee's 
primary insurance made a payment, $442.30, which exceeds the amount that Medicare would pay, $282.67. 
Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) 
and ground mileage (A0425) provided on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 a Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is 
needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from May 12, 2020, 
through May 15, 2021 at the JDEE1 payment level. 
 
You asked the Plan to pay for the SNF services as reported. You say that review of the records supports the 
Plan's finding that osteomyelitis should not have been reported for this SNF stay. As such, you state that you 
agree that the correct NTA digit for the HIPPS code is E. However, you believe that the therapy and nursing 
case mix groups were correctly documented and that they should be paid as billed. The Plan denied your 
request. The Plan says that the documentation provided does not support coding of all Section GG payment 
items which results in a reduction of the therapy and nursing case-mix grouping. The HIPPS code that is 
supported is LDQE1. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial rationale is not sufficiently specific to support the denial of the 
billed case-mix groups at issue. The Plan simply indicates that the functional scores are not supported but does 
not indicate which functional skills are incorrectly documented, nor what the Plan feels the correct scoring 
would be for these. The Plan's obligation is to support the alternate case-mix grouping it feels is appropriate for 
the PT/OT and nursing services. Review of the records provided shows no obvious discrepancy between what 
is reported in the various evaluations and what is documented in the Minimal Data Set (MDS) assessment. We 
find that the Plan's denial of the billed PT/OT and nursing case-mix groups is not substantiated. Therefore, we 
decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from May 12, 2020, 
through May 15, 2021 at the JDEE1 payment level.  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 out of network physician services provided to the enrollee on 
June 2, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have 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 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 physician services provided to the 
enrollee on June 2, 2020.