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

 
We decided that the Plan does not have to pay for office services provided from March 16, 2022, to April 13, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office services. You say that you are requesting that this be paid. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and authorization was not 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 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 office services provided from March 16, 2022, to 
April 13, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for cataract surgery provided on May 5, 2022. 
 
You asked the Plan to reduce the copayment for cataract surgery. You say that you should pay what it would 
have cost in 2020 had your surgery not been canceled. The Plan denied your request. The Plan says the 
copayment applied was 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 $350 
copayment per visit at a hospital outpatient facility.  
 
 
 
 
 
 
 
 You have been asked to pay a $350 copayment for cataract surgery. Cataract surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers, 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 reduce the copayment for cataract surgery provided 
on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 64483. You say that the provider cannot perform the procedure 
without the staff and supplies of the facility. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed. 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 64483 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 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 64483 billed for date of 
service February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99221 provided on 
January 8, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99221 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent 
at the bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99221 is not supported in the medical record. Specifically, no medical records were 
provided for the inpatient stay rendered. Without medical records, this code cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the initial hospital care services have not been met. 
Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99221 
provided on January 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 6, 2021, 
to December 29, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the submitted 
OASIS contains contradictory information 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 the services provided. Our reviewer found 
that the occupational therapy evaluation on December 10, 2021, documents a minimal assist level for toileting. 
The grooming is noted to be at a moderate independent level. This correlates with the requirement of an 
assistive device or aid, and requires more than a reasonable amount of time or there is a safety risk in 
completing the activity. The records do not support that the services were reported accurately. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from December 6, 2021, to December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that a home mechanical ventilator set in AVAPS mode with Auto-EPAP (AE) that 
could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. You have COPD with chronic CO2 retention 
and may benefit from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used 
as BiPAP. Our physician reviewer found that your condition does not meet Medicare criteria for a home 
ventilator.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 IRF admission is medically necessary. 
The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care such as a skilled 
nursing facility, 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation facility. There is 
no indication that he would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a 
week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his functional 
status. He can receive further services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 12, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist. Covered services 
include consultation, diagnosis, and treatment by a specialist. The provider billed in the amount of $85 and the 
allowed amount is $26.61. This is less than the copayment amount. Therefore, results in the total cost sharing 
amount of $26.61. 
 
 
 
 
 You have been asked to pay a $26.61 copayment, which is less than the copayment for office visit. Office visits 
fall within the Physician/Practitioner services, including doctor's office visits 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 office visit on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G device (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G device. You say that this device is medically necessary 
for the enrollee because it has been embraced by clinicians nation-wide and recommended in AHA guidelines 
for stroke rehabilitation as the only available treatment for individuals with moderate to severe upper limb 
paresis. The Plan denied your request. The Plan says there is insufficient published, peer-reviewed literature to 
evaluate the evidence related to MyoPro Orthosis for upper extremity paresis or paralysis. Medicare does not 
cover items that are experimental or investigational due to unproven safety or efficacy. 
 
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 MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient literature in the peer reviewed publications to assess 
safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for 
upper extremity paralysis/paresis from conditions such as the enrollee's brachial plexus injury, or other 
neuromuscular/neurological disease or injury. The requested device is not the standard of care for the enrollee's 
condition. The requested orthosis is not reasonable and necessary for the diagnosis, treatment of illness or 
injury or to improve the functioning of a malformed body member. 
 
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 MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on May 3, 2022. 
 
You asked the Plan to pay for a consultation. You say that you want the Plan to pay for this service. The Plan 
denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on May 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from December 14, 
2021, to December 29, 2021. 
 
You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the criteria for a continued 
SNF stay were not 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there were no identifiable skilled nursing service needs. There were no 
identifiable skilled therapy service needs. The enrollee not require skilled nursing or therapy services on a daily 
basis. The enrollee did not meet severity of illness or intensity of service criteria for an inpatient basis 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the skilled nursing services provided from December 14, 2021, to December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88342, 88360, and 
88381 provided on December 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 CPT codes 88341, 88342, 88360, and 88381 are not supported in the medical record. Specifically, 
these codes have a professional component/technical component of 1. The claim was submitted with a place of 
service 22 (outpatient hospital). The professional interpretation was furnished in the same payment locality 
from where the technical component was furnished. The Medicare rule for payment of this claim has not been 
met as the professional interpretation of a diagnostic test must be separately billed with modifier-26 by the interpreting physician. The claim was not submitted with this required modifier. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 88341, 88342, 88360, and 88381 provided 
on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (u0003, G2023) provided on April 27, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 service 
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 lab services (u0003, G2023) provided on April 27, 2022 by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of long term 
acute care hospital admission. The Plan denied your request. The Plan says based on Medicare guidelines the 
long term acute care hospital services you are requesting do not meet the requirements for approval. 
 
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 enrollee was admitted to the acute care hospital with COVID-19, treated with 
steroids and remdesivir. On the day of discharge, they were diagnosed with sepsis and diskitis requiring 
antibiotics and a cerebrovascular accident causing encephalopathy. Recent notes describe the enrollee with 
neurological deficits requiring physical and occupational therapy along with still requiring antibiotics but with 
more stable vitals and no plans for surgery.  
 
 The enrollee appears to be more stable and improving and should only require short-term additional acute care 
services that can be safely administered at the current facility until more appropriate for a lower level of care. 
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. 
 
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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided 
from April 5, 2022, to April 10, 2022. 
 
You asked the Plan to waive the copayment for inpatient care. You say that you have never had to pay for a 
hospital stay before. The Plan denied your request. The Plan says this claim was processed correctly, and your 
copayment was assessed in accordance with your contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each time you are admitted to an acute care hospital.  
 
You have been asked to pay a $300 copayment for an inpatient hospital admission. 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 admission provided from April 5, 2022, to April 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing 
provided November 21, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that this service 
was medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is 
correct, because Medicare denies coverage for all cardiovascular risk assessment tests/panels.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the cardiac risk assessment genetic screening testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the cardiac risk assessment genetic screening testing provided November 21, 
2021.