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

 
We decided that the Plan does not have to pay for the domiciliary visit provided on October 12, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that you would like the claim to be reprocessed for 
payment as the duplicate claim has been voided. The Plan denied your request. The Plan says the claim is not a 
duplicate and 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 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that domiciliary visit was urgent or emergent. Therefore, we decided 
that the Plan does not have to pay for the domiciliary visit provided on October 12, 2021, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more toward the chiropractic manipulative treatment, office visit 
and x-ray provided on March 24, 2022. 
 
You asked the Plan to pay more toward the chiropractic manipulative treatment, office visit and x-ray. You say 
that you were informed you had to pay for the initial visit, and you would be reimbursed. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms 
all cost sharing information (such as copayments, deductibles and coinsurance). The rules say that the only 
chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  
  You have been asked to pay $13.29, which is 50% of the allowed for the chiropractic manipulative treatment 
from an out-of-network provider. In addition, the office visit and x-ray remain denied because these services 
are not manual manipulation of the spine. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay more toward the 
chiropractic manipulative treatment, office visit and x-ray provided on March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 25, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on October 25, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services (99285) provided on 
August 11, 2021. 
 
You asked the Plan to pay for the emergency department services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says coding guidelines have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that claims or claim lines that have 
been determined to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. In this case, CPT code 99285 has been billed twice for the services rendered by the same provider. The record does not support payment beyond the one unit that has already paid. 
Based on this information, we decided that Medicare rules for coverage of the emergency department services 
have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department 
services (99285) provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy provided on October 25, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical nutrition therapy. You say that you have a direct, independent right 
to recover funds outside of a contract for any services provided to the Plan's enrollees. 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 
medical nutrition therapy. We found no exception that would require the Plan to pay for the medical nutrition 
therapy. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy provided on 
October 25, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 31, 2020, to 
August 10, 2020. 
 You asked the Plan to pay for the acute inpatient level of care. You say that the enrollee's hospice benefit was 
revoked on July 31, 2020. You say that the enrollee was not receiving care related to their hospice diagnosis. 
You also say that the claim should be reprocessed and paid. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, 
the new Plan is not responsible for inpatient hospital care until after the date of discharge.  
 
Your Medicare Advantage plan was not the Plan of record at the time of the inpatient stay at issue in this 
appeal began. This means that the Medicare Advantage plan is not responsible for coverage of inpatient 
hospital services until after this stay ended. Therefore, we decided that the Plan does not have to pay for the 
acute inpatient hospital care provided July 31, 2020, to August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 14, 2021, to 
August 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that you did not know that prior 
authorization was needed. The Plan denied your request. The Plan says prior 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 inpatient hospital services provided on July 14, 
2021, to August 8, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation for the enrollee. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that the enrollee needs this 
transportation to keep seeing you. The Plan denied your request. The Plan says that each one-way trip must not 
exceed 50 miles. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation 
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on March 1, 2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the item rendered is not payable. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 
 The file shows that the enrollee previously received a lumbar-sacral orthosis on June 10, 2021. The lifetime of 
this item is five years. The documentation does not support the need for replacement due to loss or irreparable 
damage. The enrollees current lumbar-sacral orthosis serves the same purpose as the lumbar-sacral orthosis 
provided. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on 
March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
January 7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a 
covered benefit. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care services 
provided on January 7, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on February 
14, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that since you had to go to the 
emergency room the next day this should be covered. The Plan denied your request. The Plan says the 
copayment 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 $50 
copayment for urgently needed services provided in an Urgent Care Center.  
 
You have been asked to pay $50 copayment for an urgent care visit. Urgent care visits fall within the Urgently 
Needed Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent care visit 
provided on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician 
reviewer found the enrollee has interstitial lung disease with a chronic cough. There is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. The chest computed tomography shows pulmonary fibrosis, 
but there is no mention of bronchiectasis. There is no convincing evidence that HFCWO is beneficial in the 
treatment of interstitial lung disease. Therefore, the enrollee does not meet criteria for the requested device. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care provided in an assisted living facility 
(Q5002) and skilled nursing services of a registered nurse (RN) (G0299) provided from October 6, 2021, to 
October 31, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health care and skilled nursing services. The Plan denied your request. 
The Plan says these services were not authorized by network/primary care providers. 
 
  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. 
Therefore, we decided that the Plan does not have to pay for the home health care provided in an assisted living 
facility (Q5002) and skilled nursing services of a registered nurse (RN) (G0299) provided from October 6, 
2021, to October 31, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from October 
28, 2021, to November 18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF stay. You say that an authorization is not required for the service that 
was rendered and you would like the claim processed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from 
October 28, 2021, to November 18, 2021, by an out-of-network (OON) provider.
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee does not meet coverage criteria for SNF care. 
 
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 the 
enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for surgery and an ultrasound provided on 
December 28, 2021. 
 
You asked the Plan to waive the copayments for surgery and an ultrasound. You say that you are not happy 
with the level of care you received so the services should be covered. The Plan denied your request. The Plan 
says the copayments applied are 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 $150 
copayment for an ultrasound and a $260 copayment for surgery or other services.  
  
You have been asked to pay $410 copayment for the surgery and an ultrasound. Surgical services fall within 
Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. An ultrasound 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 copayments for surgery and an ultrasound provided on December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the durable medical equipment (DME) provided on 
March 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse for the DME. You say that you and the enrollee were both unaware that you 
had to use an in-network provider and would like the claim reimbursed. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there are in-network providers available that the enrollee 
could have used to purchase the DME. 
 
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 reimburse 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for the durable medical equipment (DME) 
provided on March 2, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 5, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies provided on March 1, 
2022. 
 
You asked the Plan to waive the coinsurance for ostomy supplies provided on March 1, 2022. You say that you 
should not have to pay this coinsurance. The Plan denied your request. The Plan says you are responsible to 
pay a 20% coinsurance for each durable medical equipment item. 
 
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 Durable Medical Equipment (DME) and Related Supplies.  
 
You have been asked to pay a 20% coinsurance for ostomy supplies. Ostomy supplies fall within the Durable 
Medical Equipment (DME) and Related 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 
coinsurance for ostomy supplies provided on March 1, 2022.