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

 
We decided that the Plan does not have to pay for a home or residence visit provided from March 22, 2023, to 
March 24, 2023. 
 
You asked the Plan to pay for the home or residence visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a home or residence visit provided from March 22, 2023, to 
March 24, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on January 4, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for a nursing facility care visit. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says an authorization was not obtained prior to services 
rendered. 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 nursing facility care visit provided on January 4, 
2023, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
February 11, 2023, to March 10, 2023. 
 
You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the enrollee's benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from October 4, 2022, 
to February 9, 2023. The Plan has covered 100 days of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) services provided from February 11, 2023, 
to March 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 3, 
2022, to February 24, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the stay was denied after it was 
approved, and the facility was very unprofessional. 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 $0 
copayment per day for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $2,820 for a SNF stay ($188 per day x 15 days = $2,820). This item/service falls 
within the SNF 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 a SNF stay provided 
from February 3, 2022, to February 24, 2022.  
 
Your complaint about the facilitys unprofessionalism and disrespectful treatment is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from February 3, 
2023, to February 21, 2023. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you were advised the transfer to 
rehabilitation would not trigger another copayment. 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 $300 
copayment per day for days 1 to 5 for each inpatient hospital admission.  You have been asked to pay $1,500 for an IRF stay ($300 per day x 5 days = $1,500). This item/service falls 
within the inpatient hospital 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 IRF stay provided from February 3, 2023, to February 21, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for PT services provided from January 
10, 2023, to January 31, 2023, by an OON provider. 
 
You asked the Plan to increase the reimbursement for PT services. You say that you disagree with the amount 
you were reimbursed. 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 30% 
coinsurance for PT services performed by an OON provider.  
 
 
  You are being asked to pay 30% of the allowed amount for PT services ($25.81 allowed x 30% = $7.74 per 
visit x 4 visits = $30.96). You were reimbursed 70% of the allowed amount ($25.81 allowed x 70% = $72.28). 
This item/service falls within the outpatient rehabilitation 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 increase the reimbursement for PT services provided from January 10, 2023, to January 31, 2023, by an 
OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each physical therapy (PT) visit provided 
on February 03, 2023, to March 23, 2023. 
 
You asked the Plan to waive the coinsurance for each physical therapy (PT) visit. You say that you were 
advised by the facility that they were in network and you would receive a copayment. 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 30% 
coinsurance for outpatient rehabilitation services. 
 
You have been asked to pay 30% coinsurance for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total you owe is $220.80, which is 30% of the allowed amount per visit 
($73.61 allowed x 30% = $22.08 per visit x 10 visits = $220.80). Therefore, we decided that the Plan does not 
have to waive the coinsurance for each physical therapy (PT) visit provided on February 03, 2023, to March 23, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT perfusion provided on January 2, 2023. 
 
You asked the Plan to pay for a CT perfusion. You say that the enrollee with a suspected stroke/TIA will not 
leave the scanner between the performance of the CT and CTA, which are both required to diagnosis this issue. 
The Plan denied your request. The Plan says the service does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a CTA perfusion. Our reviewer says that the 
criteria to cover the CT perfusion study was not met. Our physician reviewer found Medicare does not cover a 
CT perfusion unless there is evidence on the CTA of large vessel occlusion, which is amenable to intervention. 
No such lesion is present in this case; Therefore, the criteria was not met. 
 
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 CT perfusion have not been met. Therefore, we decided that the Plan does not 
have to pay for a CT perfusion provided on January 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the throat surgery provided on January 05, 2023, to January 
07, 2023. 
 
You asked the Plan to pay for the throat surgery. You say that you were informed that no authorization was 
needed for the services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the throat surgery 
provided on January 05, 2023, to January 07, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each physical therapy (PT) visit provided 
on March 07, 2023, to March 14, 2023. 
 
You asked the Plan to reduce the copayment for each physical therapy (PT) visit. You say that you were told 
your copayment would be $25 for this service. 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 for outpatient rehabilitation services. 
 
You have been asked to pay a $25 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total you owe is $50 for the PT visits ($25 per visit x 2 visits = $50). 
Therefore, we decided that the Plan does not have to reduce the copayment for each physical therapy (PT) visit 
provided on March 07, 2023, to March 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography cerebral perfusion analysis (CTP) 
provided on December 8, 2022. 
 
You asked the Plan to pay for the CTP. You say that the records provided support medical necessity. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the CTP. Our reviewer says that the service 
is not medically necessary. Our physician reviewer found coverage guidance requires there to be CTA evidence 
of large vessel occlusion amenable to intervention in order for CT perfusion of the brain to be medically 
necessary. Review of the CTA report of January 8, 2022, showed no such lesion. 
 
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 CTP have not been met. Therefore, we decided that the Plan does not have 
to pay for a computed tomography cerebral perfusion analysis (CTP) provided on December 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on January 11, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you would like a reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on January 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 28, 
2023, to February 26, 2023. 
 You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements 
for approval. 
 
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 the enrollee does not require skilled nursing or skilled therapy services that require 
the specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does 
not require skilled services on a daily basis. The enrollee does not require skilled services on an inpatient basis 
in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from January 28, 2023, to February 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each magnetic resonance imaging (MRI) 
provided on February 06, 2023, to February 07, 2023. 
 
You asked the Plan to waive the copayment for each magnetic resonance imaging (MRI). You say that you 
were sent to the facility for the advanced imaging and were not advised of a copayment. 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 $100 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $100 copayment for each magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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. The total you owe is $200 for the advanced imaging services ($100 per 
image x 2 images = $200). Therefore, we decided that the Plan does not have to waive the copayment for each 
magnetic resonance imaging (MRI) provided on February 06, 2023, to February 07, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an MRI and a specialist visit provided 
from January 9, 2023, to February 10, 2023. 
 
You asked the Plan to waive the copayments for an MRI and a specialist visit. You say that you disagree with 
the copayment assessed. 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 $170 
copayment per provider, per date of service for complex radiology and a $35 copayment for each specialist 
visit.  
 
You have been asked to pay a $205 copayment an MRI and a specialist visit. The MRI falls within the 
outpatient diagnostic tests benefit category. The specialist visit falls within the physician/practitioner 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 copayments for an MRI and a specialist visit 
provided from January 9, 2023, to February 10, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 5, 2023, to 
March 6, 2023. 
 
You asked the Plan to pay for home health services. You say that the enrollee was not enrolled in hospice 
during the dates of service at issue. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits March 9, 2023. The services in question were provided before 
the end of that month. Given that the enrollee entered Medicare Hospice on February 14, 2023, and there were 
services prior to that date, the provider should resubmit the non-hospice portion of the home health period 
(February 5, 2023, to February 13, 2023) as a separate claim. Therefore, we decided that the Plan does not have 
to pay for home health services provided from February 5, 2023, to March 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and services provided on 
March 26, 2023. 
 
  You asked the Plan to pay for the emergency department visit and services. You say that you would like this 
claim to be reprocessed. The Plan denied your request. The Plan says the services were rendered by a non-
Medicare approved/certified freestanding emergency facility. The Plan also says that Medicare guidance 
allowing for payment on emergent hospital claims for non-Medicare certified hospitals does not apply to non-
Medicare freestanding emergency facilities. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare payment cannot be made to a provider 
that is not enrolled in the Medicare program. Medicare rules also say that Medicare covers services in an 
emergency department only if the emergency clinic is affiliated with the hospital.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The documentation provided also states that the facility in question is not an actual hospital and has 
no affiliation with a hospital. 
 Therefore, we decided that the Plan does not have to pay for the emergency department visit and services 
provided on March 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-emergency ambulance transport service. 
 
You asked the Plan to pre-approve the non-emergency ambulance transport service.. You say that the 
ambulance transport is the only way you can be seen. You also say that you are bedbound, not mobile, and use 
a lift when being moved in and out of bed, if needed. The Plan denied your request. The Plan says this is not a 
covered benefit per Medicare. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve a non-emergency ambulance transport 
service.