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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a skilled nursing facility is not the 
appropriate level of care for the enrollee. You also say that the enrollee currently meets the criteria for LTACH 
admission. The Plan denied your request. The Plan says transfer to a LTACH is not medically necessary at this 
time. 
 
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 the enrollee does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to a 
lower level of care may be considered once the enrollee is more stable in the near future. 
 
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 LTACH services.
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 your condition warrants you having inpatient 
rehabilitation. The Plan denied your request. The Plan says the documentation does not support that you meet 
Medicare criteria for an IRF. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. Our 
physician reviewer also found that 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 13, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says there is a more 
appropriate code to describe the services provided. 
 
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 the claim provided does not bill the testing at issue based on the coding and billing guidance. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant360 testing provided on April 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cancer panel provided on July 25, 2020.

You asked the Plan to pay for the testing services. You say that the enrollee does not have a personal history of cancer. The Plan denied your request. The Plan says coverage of comprehensive genomic profile testing is limited to one test per specimen.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

In this case, there was insufficient information showing the results of this testing would be used to determine a specific diagnosis or treatment strategy. The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cancer panel provided on July 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided May 1, 
2020 to May 5, 2020. 
 
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 a $275 
copayment per day for days 1-5 and a $0 copayment after day 5 for inpatient hospital care.  
 
You have been asked to pay $1,100 ($275 copayment x 4 days) for inpatient hospital 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 inpatient hospital care provided May 1, 2020 to May 5, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided on  March 23, 2020. 
 
You asked the Plan to pay for the medical services. You say that the claim is correct. The Plan denied your 
request. The Plan says the claims do not include the appropriate primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate ICD-10 code. 
 
Specifically a secondary only diagnosis code cannot be used as the primary diagnosis code. Official Guidelines 
for Coding and Reporting identify which codes maybe assigned as principal or first-listed diagnosis only, 
secondary diagnosis only, or principal/first-listed or secondary. 76937 is an add-on code so modifier 51 cannot 
be used. Based on this information, we decided that Medicare rules for coverage of the medical services have 
not been met. Therefore, we decided that the Plan does not have to pay for services provided on  March 23, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on 
January 15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that it is the facilities responsibility to 
obtain proper pre-certification and pre-authorization. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being 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 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 the domiciliary or rest home visit (99336) 
provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontics (D6240) for tooth #'s 14 and 19 provided on 
January 3, 2019 and January 16, 2019. 
 
You asked the Plan to pay for the pontics. You say that you would like a refund of your filling and upper left 
bridge so you can go to a more professional establishment to receive the help and care you need. The Plan 
denied your request. The Plan says the pontics are not valid for these teeth. 
 
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, pontics for molar teeth are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontics 
(D6240) for tooth #'s 14 and 19 provided on January 3, 2019 and January 16, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic colonoscopy (45380) provided on February 
26, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the diagnostic colonoscopy. You say that please consider the attached medical 
records to demonstrate medical necessity for the outpatient services provided. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being 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 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 the diagnostic colonoscopy (45380) provided on 
February 26, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine chiropractic services provided on June 18, 2020. 
 
You asked the Plan to pay for the services provided. You say that your condition flared up recently. The Plan 
denied your request. The Plan says your benefit maximum has been met. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan offers a chiropractic benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The file shows you received spinal manipulation on the date of service at issue. You were charged a $20 copay. 
You also received electrical stimulation. This service is considered part of routine chiropractic services. The 
records show that prior to the date of service at issue, you already received 6 supplemental visits. This means 
that you exhausted the plan benefits for routine chiropractic services. Therefore, we decided that the Plan does 
not have to pay for the routine chiropractic services provided on June 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (PSG) (95811). 
 
You asked the Plan to pre-approve a polysomnography. You say that you need to get the sleep study done to 
get the sleep machine because the one that you have is no longer working and it's been 10 months. The Plan 
denied your request. The Plan says this request is does not meet the medical necessity criteria. 
 
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 a polysomnography. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found coverage criteria for PSG are not met.  This enrollee has obstructive sleep apnea, and 
was on CPAP.  The device now requires replacement.  The records do not indicate that there have been major 
changes in the enrollee's weight or health status, or any other reason why repeat PSG would be necessary.  The 
CPAP device should be replaced.  A PSG is not medically necessary. 
 
 
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 polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polysomnography (PSG) (95811).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit (99204) and a 
diagnostic test in a pulmonary function lab (94375) performed on January 3, 2020. 
 
You asked the Plan to waive the copayments for a specialist office visit and a diagnostic test in a pulmonary 
function lab. You say that there should only be one copayment for these services. The Plan denied your request. 
The Plan says the correct copayments were applied. 
 
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 $45 
copayment for consultation, diagnosis, and treatment by a specialist, and that providers may ask you for more 
than one cost share payment if you get more than one service at an appointment. Your contract also clearly says 
that you must pay a $30 copayment for Medicare-covered non-radiological diagnostic services. 
 
You have been asked to pay $75, or a $45 copayment for a specialist office visit and a $30 copayment for a 
diagnostic test in a pulmonary function lab. A specialist office visit falls within the "Physician/Practitioner 
Services, Including Doctors Office Visits" benefit category. A diagnostic test in a pulmonary function lab 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 copayments for a specialist office visit (99204) and a diagnostic test in a pulmonary 
function lab (94375) performed on January 3, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other slower paced 
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 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. You 
are generally medically stable with old cerebrovascular accident and a chronic left hip ulcer with no evidence 
of complex medical issues that require monitoring by an inpatient physical medicine and rehab physician three 
times per week or need for acute rehab nursing care.  
 
While you may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no 
evidence of need for an intensive therapy program at the current functional tolerance level with therapy 3 hours 
per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Admission to 
IRF is not medically necessary based on lack of medical complexity and current functional status. Your rehab 
needs can be met at an alternate, low intensity level setting such as in-home with therapies and wound care. 
Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
 
 
 
 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cancer panel provided on December 16, 2019. 
 
You asked the Plan to pay for the testing services. You say that level 9 tests utilize the level of work in 
sequencing specific exons in a single gene. The Plan denied your request. The Plan says the place of service 
must reflect the location the specimen was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The claim provided lists the place of service using code 81, an independent laboratory. The records do not 
indicate the specimen tested was obtained in an independent lab. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the hereditary cancer panel provided on December 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from May 20, 2020 to 
June 3, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for days 1-20 and a $160 copayment for days 21-100 for SNF care.  
 
You had a SNF stay from May 20, 2020 to June 3, 2020. The record shows that you had a previous SNF stay 
within the same benefit period for a total of 19 days. Therefore, you are not being charged for day 20 (May 20, 
2020). You are responsible to pay a copayment for days 21-33 (May 21, 2020 to June 2, 2020) The total 
amount you owe is: $160 (copayment) x 12 (SNF days) = $1,920. 
 
You have been asked to pay the total copayment amount of $1,920 for a SNF stay. A SNF stay 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 
May 20, 2020 to June 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) 
rendered by the out of network (OON) provider on September 20, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99310) rendered by the out of network (OON) 
provider on September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician visit and injection services 
coded as 99213, 96372, G0467, J3420 provided March 30, 2020. 
 
You asked the Plan to waive the deductible for the physician visit and injection services. You say that you want 
to protest this amount because you were sent to the doctor by your attorney and this was only for a letter and a 
B12 shot. The Plan denied your request. The Plan says you are responsible for payment of a deductible when 
medical services are rendered, therefore this claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible for out of network services for Physician/practitioner 
services, including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible for out of network services. This cost sharing is a 
contractual obligation that had not been met at the time the physician visit and injection services was received 
on March 30, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the physician 
visit and injection services coded as 99213, 96372, G0467, J3420 provided March 30, 2020.