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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on July 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code [enter CPT code] is 1. The MAI value for this code is 2. You billed 2 units 
of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility (SNF) services provided to the enrollee on July 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections. 
 
You asked the Plan to pre-approve the facet joint injections. You say that you would like reconsideration 
because the requested service is medically necessary. The Plan denied your request. The Plan says there is 
record of non-facet pathology. 
 
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 facet joint injections. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is supported for predominantly axial pain that is not 
associated with radiculopathy or neurogenic claudication.  In this case, the enrollee has radiculopathy and there 
is no documentation provided indicating that the pain has been present for a minimum of 3 months with 
documented failure to respond to noninvasive conservative care 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services to be rendered out-of-area. 
 
You asked the Plan to pre-approve the home health services. You say that you would like reconsideration 
because the home health services are medically necessary. The Plan denied your request. The Plan says this 
service is not covered outside of the Plan's service area. 
 Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 home health services. Our reviewer 
says that based on the medical records provided there is documentation that you could have foreseen requiring 
the services prior to leaving your service area. Our physician reviewer found there is documentation that timely 
physical therapy and occupational therapy services were indicated after discharge from the skilled nursing 
facility. The Health Plan documents provided clearly state that home health services were not a covered benefit 
for your zip code. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health services to be rendered out-of-area.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the inpatient hospital care provided from 
November 4, 2021, through November 12, 2021. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $195 per 
day, for days 1-7 and $0 per day, for days 8-90 for inpatient hospital care. Additionally, the most you will have 
to pay out-of-pocket for in-network covered services for the year 2021 is $3,600.  
 
You have been asked to pay $1,365 ($195 copayment x 7 days) for the inpatient hospital care provided as you 
had not previously met the maximum out-of-pocket amount for the 2021 calendar year. 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 adjust the copayment for the inpatient hospital care provided from November 4, 2021, through  
November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on April 6, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate POS code. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the drug testing 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 the drug testing services (G0483) provided on April 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service December 
24, 2021. 
 
You asked the Plan to pay for procedure code 76775. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 77675 is bundled into payment for 
code 93975. 
 
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 76775 
is a column II code to column I code 93975. 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 76775 billed for date of service December 24, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bathtub handrails or grab bars 
 
You asked the Plan to pre-approve grab bars. You say that grab bars are medically necessary for safety. The 
Plan denied your request. The Plan says grab bars are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature. While this item may be appropriate for your use, neither the Plan nor 
Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve 
bathtub handrails or grab bars
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (G0299, G0300). 
 
You asked the Plan to pre-approve the home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy.  A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the home health services are not medically necessary. Our physician reviewer found the 
documentation does not show that the enrollee has needs which require skilled nursing. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services (G0299, G0300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-four (24) additional non-emergent routine 
transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are going to exceed 
your routine transportation benefit by the end of May. You are requesting an additional 24 routine transport 
trips because you do not drive, and you have no one to help you with getting to appointments. The Plan denied 
your request. The Plan says additional trips would exceed your benefit limit. 
 
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 24 trips per year.  We looked at your request, the records in the case file, and the rules. The records show that you have used 
sixteen (16) one-way transportation trips out of the allowed twenty-four (24) one-way trips approved. Once 24 
trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve twenty-four (24) additional non-emergent routine transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 27, 
2021. 
 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 October 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit on October 27, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not be subjected to 
copayment as you were seen for an annual wellness visit. The Plan denied your request. The Plan says the 
copayment applied is correct. You were seen for the annual wellness as well as for additional non-routine 
issues. 
 
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 per visit to all non-preferred PCPs for Medicare-covered services.  
 
 You have been asked to pay a $10 copayment for the office visit. The office visit 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 the office visit on October 27, 2021.
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 you need the level of care provided in an IRF. The 
Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The services you need 
can be provided in an alternate 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 that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit provided on 
August 31, 2021. 
 
You asked the Plan to waive the copayment for an emergency department visit. The Plan denied your request. 
The Plan says the claim processed and paid correctly applying the $90 copayment as your responsibility. 
 
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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for an emergency department visit. An emergency department 
visit falls within the Emergency 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 an emergency department visit provided on 
August 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluation 
(90791) provided on September 15, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $20 for 
each Medicare-covered individual visit for outpatient mental health care.  
 
You have been asked to pay a $20 copayment for the Medicare-covered individual visit for outpatient mental 
health care provided.  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 psychiatric diagnostic evaluation (90791) provided on 
September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary for your respiratory 
condition. The Plan denied your request. The Plan says your needs can be met using a BiPAP device on the 
AVAPS setting. This has not been tried yet. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable and necessary. Our physician reviewer found this patient 
has severe chronic obstructive pulmonary disease (COPD), interstitial lung disease, pulmonary hypertension, 
and congestive heart failure (CHF). There is also chronic opioid dependence. Arterial blood gases (ABG) that 
were done when the enrollee was acutely ill showed mild carbon dioxide retention. The patient may benefit from bilevel positive airway pressure (BiPAP) with Average volume-assured pressure support (AVAPS) during 
sleep. This apparently has not been tried. There is no documented failure of BiPAP. Medicare does not cover a 
home ventilator when used as BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
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 the patient cannot be discharged home safely. The 
patient is frail, elderly and very weak and discharge to home would put the patient at risk of fall or injury. You 
said that the patient is ready to be discharged and cannot be kept in the hospital. The Plan denied your request. 
The Plan says the patient does not require daily skilled therapy services on an inpatient basis. 
 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 the patient has a history of heart disease and 
hypertension and suffered a fracture of his left hip on March 29, 2022. He had hip replacement surgery on 
April 1, 2022. Since then, the patient has been able to ambulate up to 160 feet. The patient does not have any 
skilled nursing needs but does have skilled therapy needs. However, the documentation does not support that it 
is medically reasonable and necessary to provide skilled therapy services on a daily basis on an inpatient basis, 
in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection (J0897) provided 
on August 5, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service 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-covered Part B drugs and other outpatient services.   
 
You have been asked to pay $251.66 (Plans allowed amount of $1,258.32 x 20% coinsurance) for the 
Medicare Part B drug provided.  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 denosumab injection (J0897) provided on August 5, 
2021.