Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs acute care to be safely discharged. 
The Plan denied your request. The Plan says the enrollee's care is not complex, and does not need a team of 
providers. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for weakness and falls. His medical conditions are stable. 
The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 
 
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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services 
but does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee 
will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 
an inpatient rehabilitation facility due to her cognitive status and weakness. Care at the skilled nursing facility 
level appears to be more appropriate in this case. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the specialist office visit and the 
chemotherapy injections provided on March 4, 2020 
 
You asked the Plan to reduce the cost share for the specialist office visit and the chemotherapy injections. You 
say that you say the member previously paid significantly less for the same service. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing 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 $35 
copayment for each in-network specialist visit for Medicare-covered service and 20% of the plan-allowed 
amount for in-network Medicare Part B-covered chemotherapy drugs.  
 
The member has been asked to pay a total of $1,240.56 for the specialist office visit and the chemotherapy 
injections. The specialist office visit falls within the 'Physician/Practitioner services, including doctor's office 
visits' benefit category. The chemotherapy injections fall within the 'Medicare Part B prescription drugs' 
benefit category. See chart below. 
  
 
Date of Service Service Allowed Amount Copayment/Coinsurance Member 
Liability 
March 4, 2020 Specialist office 
visit 
$125.61 $35.00 $35.00 
March 4, 2020 Chemotherapy 
injections 
$6,027.78 20% $1,205.56 
Total    $1,240.56 
 
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 reduce the cost share for the specialist office visit and the chemotherapy injections 
provided on March 4, 2020. 
 
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact 
the plan directly.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to approve continued skilled nursing facility (SNF) services beyond December 
20, 2020. 
 
You asked the Plan to approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before December 20, 2020. The Plan issued a Notice of Denial of Medical Coverage (NDMC) for 
this appeal, which is the incorrect notice for these services. The Plan must pay for SNF services until the 100-
day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. 
Therefore, we decided that the Plan has to approve continued skilled nursing facility (SNF) services beyond 
December 20, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the clinic visit provided on August 26, 
2020. 
 
You asked the Plan to waive the copayment for the clinic visit. You say that you should only be responsible for 
your regular copayment. You say there should be no additional charges because this was follow-up visits and 
did not have any procedures or treatments. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing 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 $30 
copayment for specialist for each in-network outpatient clinic visit.  
 
You have been asked to pay a $22.84 copayment, which is less than the standard amount, for the clinic visit. 
The clinic visit falls within the Outpatient hospital services benefit category. The medical record shows you 
were seen for an office visit. 
 
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 clinic visit provided August 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intense physical rehab and 
neuro checks. The Plan denied your request. The Plan says the records do not support the ability tolerate an 
intensive rehab therapy program. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for surgical treatment of a hip fracture after a fall. Her 
medical conditions are stable. The complexity of her nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a 
reasonable expectation that she will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital stay for surgery. 
 
You asked the Plan to pre-approve an acute inpatient hospital stay. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 an acute inpatient hospital stay. Our 
reviewer says that the documentation does not support that the criteria for an inpatient stay are met in this case. 
Our physician reviewer found the approved surgical procedure is not on the Medicare Inpatient Only List. The 
enrollee is noted to have no significant uncontrolled chronic conditions that pre-operatively would warrant an 
in-patient level of care. There is no specific clinical rationale for the requested inpatient services. If the enrollee 
undergoes the procedure and intra- or post-operatively requires care that meets an inpatient level of services, 
then the Plan would approve inpatient care as an observation conversion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an acute inpatient hospital stay have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an acute inpatient hospital stay for surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the charges for the inpatient mental health stay provided from 
July 13, 2020, to July 27, 2020. 
 
You asked the Plan to adjust the charges for the inpatient mental health care. You say that you are being asked 
to pay for $50,000 which you cannot afford to pay. The Plan denied your request. The Plan says review of the 
bill from this provider shows that after insurance payment was made, you only owe the $1763 described in 
your EOC for this stay. 
 
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 $1763 
copayment per stay for inpatient mental health care.  
 
You have been asked to pay a $1763 copayment for the inpatient mental health stay. 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 charges for the inpatient mental health stay provided from July 13, 2020, to July 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train of four testing provided. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is a bundled service. 
 
The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a 
procedure are considered a component part of a comprehensive code. 
 
IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered 
integral to the performance of IONM services. As such, this component of the procedure is included in 
payment for the overall IONM monitoring service which was already paid. No separate payment can be made 
for this part of the service. Therefore, we decided that the Plan does not have to pay for the train of four testing 
provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 2.5 mg tablets. 
 
You asked the Plan to pre-approve Eliquis. You say that this service is medically necessary. The Plan denied 
your request. The Plan says medications are not covered. This medication does not fall under Part B. 
 
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 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 Eliquis 2.5 mg tablets.  
 
Benefits for Eliquis 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 pay for physician services provided on June 12, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 physician services provided on June 12, 2020, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9338 provided on 
August 10, 2020. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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, the CPT Code Manual definition of code S9338 is home infusion therapy, immunotherapy, 
administrative services, professional pharmacy services, care coordination, and all necessary supplies and 
equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9338 is not supported in the medical record. Specifically, this CPT code has a status 
code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another 
code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules 
for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9338 provided on August 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided to the enrollee on September 
16, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide 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 practitioner services provided 
to the enrollee on September 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on August 19, 
2020. 
 
You asked the Plan to pay for digital breast tomosynthesis. You say that this is a valid code. The Plan denied 
your request. The Plan says this code is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77062 is not supported in the medical record. Specifically, this code has a status 
indicator of I. Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of digital breast tomosynthesis have not been met. 
Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on 
August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on July 20, 2020. 
 
You asked the Plan to pay for the gingival irrigation. You say that you were not aware you needed to get 
approval for these services. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921) provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 13, 2020, and 
billed under codes 81210 and 81275. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met as the claim submitted is lacking the required codes 
for this testing.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted is lacking the codes 
required to pay this claim in full. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on May 13, 2020, and billed under codes 81210 and 81275.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on June 10, 2020 
and billed under codes A9505 (4 units) and J0280 (1 unit). 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code A9505 (4 Units) remains 
not supported. The Plan says that the documentation submitted did not include documentation indicating that 
thallium Tl-201 thallous chloride, diagnostic, per mCi was administered; therefore, the billed service cannot 
be verified. In addition, there is insufficient documentation to support the billing of code J0280 (1 Unit) . The 
records did not include documentation indicating that an injection, aminophylline, up to 250 mg was 
administered; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to 
contact the provider for additional information.  The Plan states they have insufficient documentation to 
corroborate the services submitted on the claim.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide medical records that support the services 
billed. In this case, review of the records provided do not support the billing of codes A9505 (4 units) and 
J0280 (1 unit).  Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for injection services provided to the enrollee on June 10, 2020 and billed under 
codes A9505 (4 units) and J0280 (1 unit).