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

We decided that the Plan does not have to pay for the telehealth service provided on September 7, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the telehealth service. You say that the service was medically necessary. The
Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the telehealth service provided on September 7, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on September 8, 2021, by an out-of-network provider.
You asked the Plan to pay for wound care services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for wound care services provided on September 8, 2021, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport
(A0998) provided on August 7, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you went
out to eat and passed out. You also say that you were given the option of going to the hospital or going home to
continue taking fluids and monitor, and you chose to let your wife drive you home and drink plenty of fluids.
The Plan denied your request. The Plan says this service is not covered under Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on August 7, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no
transport (A0998) provided on August 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an
LTACH are not met. The enrollee's medical needs are being met in the current acute setting; the LTACH would
provide no additional services. With more time in the current setting, clinical stability can be ensured such that
the appropriate lower level of care can be determined.
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 there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where he is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for intramuscular diagnostic injections
provided from March 10, 2021, to September 8, 2021.
You asked the Plan to waive the copayments for intramuscular diagnostic injections. You say that you never
had to pay a copayment for these injections in the past. The Plan denied your request. The Plan says the claims
were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for primary care provider visits.
You received intramuscular diagnostic injections provided from March 10, 2021, to September 8, 2021, for a
total of 7 injections. Therefore, you are responsible to pay a $10 copayment per each visit.
The total amount you owe is: $10 (copayment) x 7 (injections) = $70.
You have been asked to pay the total copayment amount of $70 for intramuscular diagnostic injections.
Intramuscular diagnostic injections 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 copayments for intramuscular diagnostic
injections provided from March 10, 2021, to September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient hospital care provided on March 23, 2021.
You asked the Plan to waive the deductible for inpatient hospital care. You say that you should only owe a $350 copayment and request a refund. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible which applies to inpatient hospital care. You received inpatient hospital care on March 23, 2021. The record shows that you had only paid $31.20 toward the $1,000 deductible. Now that the deductible has been met, you are responsible to pay the remaining deductible balance of $968.80. The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient
hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time inpatient hospital care was received on March 23, 2021. Therefore, we decided that the Plan does not have to waive the deductible for inpatient hospital care provided on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcatheter tricuspid valve repair.
You asked the Plan to pre-approve the requested services. You say that this is the only current option for the
enrollee. The Plan denied your request. The Plan says there is not enough medical proof for the success of this
treatment.
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 the requested services. Our physician
reviewer found that the enrollee has a history of severe tricuspid regurgitation, chronic congestive heart failure,
and preserved left ventricular function. There are insufficient randomized clinical data at this time to support
the use of the requested procedure in this setting. As such, it would not be considered medically appropriate
and necessary in this enrollee's management.
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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a transcatheter tricuspid valve repair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998)
provided on September 2, 2021.
You asked the Plan to pay for the ambulance service. You say that you were enroute to an out of state wedding
when you required medical assistance. You also say that you were not aware the services would not be
covered. The Plan denied your request. The Plan says there was no transport provided on the date of service in
this case. The Plan also says that since no transport was provided, there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 2, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no
transport, (A0998) provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for influenza vaccination services received on October 29, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The
Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the services.
Therefore, we decided that the Plan does not have to pay for influenza vaccination services received on
October 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from August 30, 2021, to
September 3, 2021, by a provider who is not Medicare-certified.
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the
services were rendered by a provider who is not under contract with the health Plan. The Plan also says that the
treating provider is not a Medicare-certified provider.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a provider or supplier must be enrolled in the Medicare program.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health services have not been met. This provider is not part of the Medicare program and
is not payable. Therefore, we decided that the Plan does not have to pay for the home health services provided
from August 30, 2021, to September 3, 2021, by a provider who is not Medicare-certified.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services (92014) provided on September
22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for ophthalmological services. You say that the provider has no prior knowledge of
which patients he will be required to see. You also say that once he arrives at the facility, he receives a list of
patients who require psychiatrist care, and he must provide services to all of them since there is currently no innetwork
doctor who can treat the patients in this facility. The Plan denied your request. The Plan says an
authorization was not obtained prior to the services being rendered and the provider is not participating with the
member's Plan. The Plan also says that it was determined the services were not urgent or emergent in nature.
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 ophthalmological services (92014) provided on
September 22, 2021, by an out-of-network (OON) provider.
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 enrollee is able to participate in at least 3 hours of therapy per day at least 5 days per week or at least 15 hours of intensive rehabilitation therapy within a 7-consecutive day period. You say that the enrollee is currently at a contact guard assist to minimal assist level for therapy with a diagnosis of fractured femur. You say that the enrollee will continue to require medical supervision by a multi-disciplinary team. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive the care needed in another 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diabetic shoes and inserts provided on
August 16, 2021.
You asked the Plan to waive the deductible for the diabetic shoes and inserts. You say that you did not receive
these services. The Plan denied your request. The Plan says that the provider included records to confirm you
received these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $500 deductible which applies to the diabetic shoes and inserts.
The item or service you asked the Plan to waive the deductible for falls within the benefit category the diabetic
shoes and inserts. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$500 deductible which applies to the diabetic shoes and inserts. This cost sharing is a contractual obligation
that had not been met at the time the diabetic shoes and inserts was received on August 16, 2021. Therefore, we
decided that the Plan does not have to waive the deductible for the diabetic shoes and inserts provided on
August 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sildenafil Citrate.
You asked the Plan to pre-approve Sildenafil Citrate. You say that the enrollee requires treatment of pulmonary
arterial hypertension. The Plan denied your request. The Plan says this drug is not covered under the Part B
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sildenafil Citrate.
Benefits for Sildenafil Citrate may be available under Medicare Part D. Contact the Plan that administers Part
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs received on September 20, 2021, and
September 21, 2021.
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B.
Therefore, we decided that the Plan does not have to pay for self-administered drugs received on September 20,
2021, and September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing (81295 and 81298) provided on July 15, 2021.  You asked the Plan to pay for lab tests 81295 and 81298. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because codes 81295 and 81298 have a Procedure-to-Procedure (PTP) edit of 0 with code 81432 so are not separately payable.  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, we have confirmed that codes 81295 and 81298 are column II codes to column I code 81432. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (81295 and 81298) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided
on August 23, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree
with the charges and would not have had the injection if you had known how much you would owe. The Plan
denied your request. The Plan says the claims were processed correctly, and you are being charged the correct
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug injection on August 23, 2021. The total allowed amount is $1,278 and
20% of that is $255.60.
You have been asked to pay the total coinsurance amount of $255.60 for a Medicare Part B drug injection. A
Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the coinsurance for a Medicare Part B drug injection provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the sleep apnea appliance (D5999) provided on July 19, 2021.  You asked the Plan to reimburse you for the dental item. You say that this is a medical condition, not dental. You say that dental professionals are the providers of this appliance. You also say that you should be reimbursed for this service. The Plan denied your request. The Plan says that the claim processed correctly.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the sleep apnea appliance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the sleep apnea appliance (D5999) provided on July 19, 2021.