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

 
We decided that the Plan does not have to waive the coinsurance for the out-of-network acupuncture services 
you received from July 21, 2021, to August 10, 2021. 
 
You asked the Plan to waive the coinsurance for the out-of-network acupuncture services. You say that you 
paid out of pocket for these claims, so you should have been reimbursed for these services. The Plan denied 
your request. The Plan says you were charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for out-of-network acupuncture services.  
 
 
 You have been asked to pay 50% coinsurance for the out-of-network acupuncture 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 coinsurance for the out-of-network acupuncture services you received from July 21, 
2021, to August 10, 2021.  
 
Your complaint about the provider getting paid instead of you getting reimbursed 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection, anesthetic agent; lumbar or thoracic (64520) 
rendered by the out-of-network (OON) provider on August 30, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the injection, anesthetic agent; lumbar or thoracic (64520) rendered by the out-of-
network (OON) provider on August 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care would provide the enrollee 
with the best opportunity for recovery. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage. 
 
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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that the requested admission to an IRF is not medically 
necessary. 
 
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 found to be medically reasonable and necessary. Our physician reviewer found you are 
medically stable with paraplegia related problems and still need physician supervision 3 times per week (at a 
minimum) for the ongoing management of spasticity, pain and orthostatic hypotension and any acute 
exacerbations of chronic medical conditions. At the current functional level, you need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy in an IRF. During IRF and skilled nursing facility (SNF) stays, you were in a thoracic lumbar 
sacral orthosis (TLSO) limiting your ability to be functional and now that the TLSO was discontinued, you 
need an opportunity to use your upper extremities and be more functional. You need an appropriate wheelchair 
to work towards independence in transfers and mobility and improve your quality of life. Your rehabilitation 
needs cannot be met safely at a lower intensity and alternate setting such as in an SNF. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee is on 
immunosuppressive medications. Therefore, he is at a high risk for opportunistic infection. His cough and prior 
abnormal CT provide ample evidence of the medical necessity of the requested chest scan. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
a computed tomography (CT) scan of the thorax for the enrollee.  
 
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 the moderate sedation services (99153) provided on August 
26, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99153). You say that the attached medical 
records support the procedures billed and you believe they are medically necessary. You say that the services 
meet the definition required for payment and the claim should be reimbursed. The Plan denied your request. 
The Plan says CPT codes 92928, 92928, 92920, 93458 and 99152 will be covered. The Plan also says CPT 
code 99153 is not separately payable when performed by a physician in a facility setting. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to pay any physician or vendor. Based on 
this information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have 
not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services 
(99153) provided on August 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic aneurysm screening (76706) provided 
on November 19, 2021. 
 
You asked the Plan to pay for the screening test. You say that this is too much. You also say that this should be 
covered more than once in a lifetime in order to get tested for these ailments. The Plan denied your request. 
The Plan says the benefit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the screening test have not been met. Specifically, the file shows that the Plan paid for an 
abdominal aortic aneurysm screening that you received on February 22, 2019. Therefore, we decided that the 
Plan does not have to pay for the abdominal aortic aneurysm screening (76706) provided on November 19, 
2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator trial is subject to the criteria 
listed 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 a spinal cord stimulator trial. Our 
reviewer says that the requested spinal cord stimulator is medically reasonable and necessary. Our physician 
reviewer found that the enrollee is a 54-year-old gentleman who has chronic low back and cervical pain. He is 
currently taking oxycodone, Gabapentin, and Norco. He is status post L5-S1 fusion. The Plan refers to an intra-
thecal pump, but it is not described in the imaging reports submitted. He has had a psychological evaluation 
and has been seen by a multi-disciplinary team. The request meets the criteria for a spinal cord stimulator trial 
and the request is medically reasonable and 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 a spinal cord stimulator trial have been met. Therefore, we decided that the Plan 
has to pre-approve a spinal cord stimulator trial.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that your attending doctor has told you they 
feel LTACH is where you need to be admitted and that you meet the criteria for the admission. The Plan denied 
your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan states when 
you are ready to leave the hospital, you can safely receive this care in another setting, such as a skilled nursing 
facility (SNF) or at home with home health services or outpatient setting if appropriate. 
 
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 you appear to be stable and improving and requires only short-term additional acute 
care services that can safely be administered at the current facility. You do not require services at the LTACH 
that are not already available at the current facility. There are no services at the LTACH that you require that 
are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it 
would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment is 
completed. 
 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a methylprednisolone injection (J1030) and 
an x-ray (73564) provided on October 27, 2021. 
 
You asked the Plan to waive the copayment for the methylprednisolone injection and x-ray. You say that the 
services should be covered as they were not helpful and you did not see a doctor, only a physicians assistant. 
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 20% 
coinsurance for Medicare Part B prescription drugs and the administration of them and a $35 copayment for 
Outpatient diagnostic tests and therapeutic services and supplies.  
 You have been asked to pay a 20% coinsurance for a methylprednisolone injection (allowed is $11.26 x 20% = 
$2.25) and a $35 copayment for an x-ray. Methylprednisolone injections fall within the Medicare Part B 
prescription drugs benefit category and x-rays fall 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 a 
methylprednisolone injection (J1030) and an x-ray (73564) provided on October 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from February 18, 2022, 
forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says your request does not meet Medicare guidelines because you no longer require 
skilled services and the continuation of SNF is not medically necessary. 
 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 there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF 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 pre-approve continuation of SNF care from February 18, 2022, forward.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on September 21, 
2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER and did not get 
the treatment you went for. You say that you should not be responsible for the bill. The Plan denied your 
request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for Medicare- covered emergency room visits.  
 
 
  You have been asked to pay a $100 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show you received laboratory services and a computed tomography scan during 
the visit. 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 ER visit provided on September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient acute admission for a right total hip arthroplasty. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation provided to support the expectation the enrollee 
will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is an 83 year old male with hip osteoarthritis who is planning an elective 
right total hip arthroplasty. This is a request for inpatient services during and after this procedure. The provided 
documentation including the preoperative clearance note describe the patient as stable for the procedure and 
should not require inpatient services. The enrollee is not expected to require hospital services that would likely 
cross 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient acute admission for a right total hip arthroplasty.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on August 31, 2021. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered. 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 $20 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 
 
 
 You have been asked to pay a $20 copayment for an x-ray. X-rays fall within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The record indicates that there is no history of these 
services being waived before by this provider. 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 x-ray 
provided on August 31, 2021.