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

 
We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services provided to 
the enrollee from March 26, 2022 to April 24, 2022. 
  
You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says skilled therapy or skilled nursing services were not provided during this time period. 
 
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 is no documentation that skilled nursing services were provided. There are 
no daily physical therapy or occupational therapy notes from this time period. The enrollee did not receive 
rehabilitation services during the time frame of 3/26/22 to 4/24/22 which would be considered skilled services 
by Medicare. There is no documentation that the enrollee received a frequency of skilled therapy services 
warranting SNF level of care during the time frame under review. Neither was there documentation of nursing 
services. 
 
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 continued skilled nursing facility (SNF) services provided to the enrollee from March 26, 2022 to 
April 24, 2022.
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 the enrollee needs LTACH care. The 
Plan denied your request. The Plan says the clinical assessment does not support the expectation of a stay to be 
at least 25 days. Criteria for admission to the LTACH have not been met. The enrollee's medical needs are 
being met in the current acute setting. The LTACH would add no additional services. With additional 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 yhe patient is a 79-year-old male who was admitted to the acute care hospital with 
pulmonary embolism and deep vein thrombosis complicated by acute respiratory failure and requiring 
hemicolectomy, lysis of adhesions for adenocarcinoma and further complicated by non-ST myocardial 
infarction. He was treated with mechanical ventilations support, total parenteral nutrition, trach placement, wound care including wound VAC, PEG placement, anticoagulation, and antibiotics. Recent notes describe the 
patient as now tolerating trach collar trials but still requiring wound care and monitoring. The patient appears to 
be more stable and improving now and should only require short-term additional acute care services that can 
safely be provided at the current facility until more stable and appropriate for a lower level of care. The patient 
does not require services at the LTACH that are not already available at the current facility. Transfer to the 
LTACH is not medically necessary as it would not be clinically advantageous at this time. Completion of 
treatment at the current facility is recommended.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on August 
13, 2022, to August 14, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you had a terrible hospital 
stay so you shouldnt have to pay anything. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $395 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $395 copayment for inpatient hospital stay. This item/service falls within the 
Inpatient hospital care 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 inpatient 
hospital stay provided on August 13, 2022, to August 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram and an 
echocardiography on April 6, 2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram and an echocardiography. You say that 
you would like to appeal the cost share. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $25 
copayment and a $60 copayment for an electrocardiogram and an echocardiography. The allowed amount for 
the $25 copayment is $14.91, which is less than the normal copayment, therefor the total cost share is $74.91. 
 
You have been asked to pay a $25 copayment and a $60 copayment for an electrocardiogram and an 
echocardiography. This item/service 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 copayment for an electrocardiogram and 
an echocardiography on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an office visit provided on February 28, 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 office visit (99214) provided on March 
23, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says this cost sharing was charged 
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 $10 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $10 copayment for the office visit. This item/service falls within the 
Physician/Practitioner services, including doctors 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 an office visit (99214) provided on March 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on June 21, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on June 21, 2022.  
 Benefits for these items 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for A magnetic resonance imaging (MRI) and 
an orthopedic visit provided on April 26, 2022, and April 29, 2022. 
 
You asked the Plan to waive the copayment for an MRI and an orthopedic visit. You say that you have never 
had all of these copayments before, why now? The Plan denied your request. The Plan says this cost sharing 
was charged 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 $250 
copayment for outpatient diagnostic tests and therapeutic services and supplies, and a $30 copayment for 
physician/practitioner services, including doctors office visits. 
 
You have been asked to pay the allowed amount of $236.67 which is less than the $250 copayment for an MRI 
and $30 for an orthopedic visit ($236.67 + $30 = $266.67). This means your total copayment is $266.67. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies, and 
physician/practitioner services, including doctors 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 A magnetic resonance imaging (MRI) and an orthopedic 
visit provided on April 26, 2022, and April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional rides 
because you have appointments to attend before your open-heart surgery in December. The Plan denied your 
request. The Plan says you have exhausted your routine transport benefit and there are no exceptions to this 
rule. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for NavDX testing (code 81479) provided on April 8, 2022. 
 
You asked the Plan to pay for the testing. You say that your testing greatly reduces medical expenses. The Plan 
denied your request. The Plan says documentation supporting the medical necessity of the testing was not 
provided by you. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician 
who is treating the beneficiary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. The case file does not contain an order from the treating physician. 
Therefore, we decided that the Plan does not have to pay for NavDX testing (code 81479) provided on April 8, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport rendered on January 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.   
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee presented to the emergency 
department on January 2, 2022 with abdominal pain and nausea. The evaluation revealed cholelithiasis. There 
was no documentation of hemodynamic instability or sepsis. He required transfer to another facility as there 
were no gastroenterology services available. He was transferred via air ambulance. He required intravenous 
(IV) fluids, supplemental oxygen, and telemetry monitoring during transport. The documentation did not 
support that the enrollee's condition was such that the time needed to transport a patient by ground, or the 
instability of transportation by ground, posed a threat to the enrollee's survival, or seriously endangered the 
enrollee's health. The documentation did support that the transferring hospital did not have adequate facilities 
to provide the medical services needed by the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the air ambulance transport rendered on January 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9610), an evaluation for 
moderate sedation (D9219), deep sedation (D9222, D9223), and the removal of impacted tooth #32 (D7230). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and need these services. 
The Plan denied your request. The Plan says the requested items and services are not covered by your dental 
benefits. 
 
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 pre-approve 
therapeutic parenteral drugs (D9610), an evaluation for moderate sedation (D9219), deep sedation (D9222, 
D9223), and the removal of impacted tooth #32 (D7230).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service is medically necessary and should be 
paid. 
 The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided from 
February 1, 2022, to March 29, 2022. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that your mother did 
better at home in 6 weeks than she did in three months in the SNF. Please reconsider this amount. The Plan 
denied your request. The Plan says this cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $75 copayment per day for days 21 to 100 for Skilled nursing facility (SNF) care ($50 x 28 days = 
$1400 + $400 for the remaining days = $1800). 
 
The enrollee has been asked to pay an $1800 copayment per day for days 21 to 100 for a skilled nursing facility 
stay. This item/service falls within the Skilled nursing facility (SNF) care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for a skilled nursing facility stay 
provided from February 1, 2022, to March 29, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis treatments provided on March 19, 
2022 to July 23, 2022 
 
You asked the Plan to waive the coinsurance for the dialysis treatments. You say that the services should be 
covered as you disagree with the charges and they would cause a financial hardship. The Plan denied your 
request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Services to treat kidney disease.  
 
 
  You have been asked to pay a 20% coinsurance for the dialysis treatments. This item/service falls within the 
Services to treat kidney disease 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 
dialysis treatments provided on March 19, 2022 to July 23, 2022
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 code 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 6, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 13, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 code 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service August 13, 2022.